Levosimendan: current status and future prospects

An overview of pyridazin-3(2H)-one: a core for developing bioactive agents targeting cardiovascular diseases and cancer

Cardiovascular diseases (CVDs) and cancer are the top two leading causes of death globally. Vasodilators are commonly used to treat various CVDs. In cancer treatment, targeted anticancer agents have been developed to minimize side effects compared with traditional chemotherapy. Many hypertension patients are more prone to cancer, a case known as reverse cardio-oncology. This leads to the search for drugs with dual activity or repurposing strategy to discover new therapeutic uses for known drugs. Recently, medicinal chemists have shown great interest in synthesizing pyridazinone derivatives due to their significant biological activities in tackling these critical health challenges. This review will concentrate on pyridazin-3(2H)-one-containing compounds as vasodilators and anticancer agents, along with a brief overview of various methods for their synthesis.

Novel Treatments of Hypertrophic Cardiomyopathy in GDMT for Heart Failure: A State-of-art Review

This state-of-the-art review discuss the available evidence on the use of novel treatments of hypertrophic cardiomyopathy such as omecamtiv mecarbil, EMD-57033, levosimendan, pimobendan, and mavacamten for the treatment of heart failure (HF) in the context of guideline-directed medical therapy (GDMT). The paper provides a detailed overview of these agents' mechanisms of action, potential benefits and limitations, and their effects on clinical outcomes. The review also evaluates the efficacy of the novel treatments in comparison to traditional medications such as digoxin. Finally, we seek to provide insight and guidance to clinicians and researchers in the management of HF patients.

Levosimendan as a therapeutic strategy to prevent neuroinflammation after aneurysmal subarachnoid hemorrhage?

BACKGROUND

Poor patient outcomes after aneurysmal subarachnoid hemorrhage (SAH) occur due to a multifactorial process, mainly involving cerebral inflammation (CI), delayed cerebral vasospasm (DCVS), and delayed cerebral ischemia, followed by neurodegeneration. CI is mainly triggered by enhanced synthesis of serotonin (5-HT), prostaglandin F2alpha (PGF2a), and cytokines such as interleukins. Levosimendan (LV), a calcium-channel sensitizer, has already displayed anti-inflammatory effects in patients with severe heart failure. Therefore, we wanted to elucidate its potential anti-inflammatory role on the cerebral vasculature after SAH.

METHODS

Experimental SAH was induced by using an experimental double-hemorrhage model. Sprague Dawley rats were harvested on day 3 and day 5 after the ictus. The basilar artery was used for isometric investigations of the muscular media tone. Vessel segments were either preincubated with LV or without, with precontraction performed with 5-HT or PGF2a followed by application of acetylcholine (ACh) or LV.

RESULTS

After preincubation with LV 10^-4 M and 5-HT precontraction, ACh triggered a strong vasorelaxation in sham segments (LV 10^-4 M, E_max 65%; LV 10^-5 M, E_max 48%; no LV, E_max 53%). Interestingly, SAH D3 (LV 10^-4, E_max 76%) and D5 (LV 10^-4, E_max 79%) segments showed greater vasorelaxation compared with sham. An LV series after PGF2a precontraction showed significantly enhanced relaxation in the sham (P=0.004) and SAH groups (P=0.0008) compared with solvent control vessels.

CONCLUSIONS

LV application after SAH seems to beneficially influence DCVS by antagonizing 5-HT- and PGF2a-triggered vasoconstriction. Considering this spasmolytic effect, LV might have a role in the treatment of SAH, additionally in selected patients suffering takotsubo cardiomyopathy.

Synthesis, spectroscopy, crystal structure, TGA/DTA study, DFT and molecular docking investigations of (E)-4-(4-methylbenzyl)-6-styrylpyridazin-3(2H)-one

In this study, we present the synthesis of novel pyridazin-3(2H)-one derivative namely (E)-4-(4-methylbenzyl)-6-styrylpyridazin-3(2H)-one (MBSP). The chemical structure of MBSP was characterized using spectroscopic techniques such as FT-IR, 1H NMR, 13C NMR, UV-Vis, ESI-MS, and finally, the structure was confirmed by single X-ray diffraction studies. The DFT calculation was performed to compare the gas-phase geometry of the title compound to the solid-phase structure of the title compound. Furthermore, a comparative study between theoretical UV-Vis, IR, 1H- and 13C NMR spectra of the studied compound and experimental ones have been carried out. The thermal behavior and stability of the compound were analyzed by using TGA and DTA techniques which revealed that the compound is thermostable up to its melting point. Finally, the in silico docking and ADME studies are performed to investigate whether MBSP is a potential therapeutic for COVID-19.

[4 + 2] Annulation Reaction of In Situ Generated Azoalkenes with Azlactones: Access to 4,5-Dihydropyridazin-3(2H)-Ones

An unprecedented [4 + 2] annulation reaction between in situ formed azoalkenes and azlactones has been developed. This reaction provides a facile access to an array of 4,5-dihydropyridazin-3(2H)-one derivatives, which are very promising in medicinal applications as potential biologically active candidates. Notably, these dihydropyridazinones could also be synthesized via a one-pot reaction protocol by using the in situ formed azlactones from N-acyl amino acids and in situ generated azoalkenes from α-halogeno hydrazones. The potential applications of the methodology were also demonstrated by gram-scale experiments and the versatile conversions of the products into other nitrogen-containing compounds.

Polymorphism of 2-(5-benzyl-6-oxo-3-phenyl-1,6-di-hydro-pyridazin-1-yl)acetic acid with two monoclinic modifications: crystal structures and Hirshfeld surface analyses

Two polymorphs of the title compound, C19H16N2O3, were obtained from ethano-lic (polymorph I) and methano-lic solutions (polymorph II), respectively. Both polymorphs crystallize in the monoclinic system with four formula units per cell and a complete mol-ecule in the asymmetric unit. The main difference between the mol-ecules of (I) and (II) is the reversed position of the hy-droxy group of the carb-oxy-lic function. All other conformational features are found to be similar in the two mol-ecules. The different orientation of the OH group results in different hydrogen-bonding schemes in the crystal structures of (I) and (II). Whereas in (I) inter-molecular O-H⋯O hydrogen bonds with the pyridazinone carbonyl O atom as acceptor generate chains with a C(7) motif extending parallel to the b-axis direction, in the crystal of (II) pairs of inversion-related O-H⋯O hydrogen bonds with an R 2 2(8) ring motif between two carb-oxy-lic functions are found. The inter-molecular inter-actions in both crystal structures were analysed using Hirshfeld surface analysis and two-dimensional fingerprint plots.

Synthesis and vasodilator activity of some pyridazin-3(2H)-one based compounds

Aim: Hypertension is a major health problem worldwide resulting in high death rates due to its consequences and complications. Therefore, searching for new vasorelaxants is a must to find new vasodilators efficient for the treatment of different cardiovascular diseases. Methodology: Different 6-phenyl-3-pyridazinone based derivatives were synthesized and screened for their vasorelaxant activity according to the reported method using hydralazine as a standard. Results: The tested compounds revealed potent to mild activity with EC50 values 0.339–114.300 μM compared with hydralazine EC50 = 18.210 μM. Conclusion: The most active compounds were the acid 5, its ester analog 4 and 4-methoxyphenylhydrazide derivative 10c (EC50 = 0.339, 1.225 and 1.204 μM, respectively). Therefore, 6-phenylpyridazin-3(2 H)-one can be a hit for structural optimization to obtain promising vasorelaxants.

Pyridazinone: an attractive lead for anti-inflammatory and analgesic drug discovery

In spite of the availability of a large number of anti-inflammatory and analgesic agents, fighting pain and inflammation remains a common problem. The current review article discusses the need of novel therapeutic targets for risk-free anti-inflammatory and analgesic therapy and summarizes some new agents in various stages of drug discovery pipeline. Pyridazin-3(2H)-ones are nitrogen-rich heterocyclic compounds of considerable medicinal interest due to their diverse biological activities. The current review article focuses on progressive development of this attractive scaffold for the design and synthesis of new pyridazinone-based anti-inflammatory and analgesic agents. Mechanistic insights into the anti-inflammatory and analgesic properties of pyridazinone derivatives and various synthetic techniques used for their synthesis are also described.

Levosimendan, a new therapeutic approach to prevent delayed cerebral vasospasm after subarachnoid hemorrhage?

BACKGROUND

Under physiological cerebral conditions, levosimendan, a calcium-channel sensitizer, has a dose-dependent antagonistic effect on prostaglandin F2alpha (PGF)-induced vasoconstriction. This circumstance could be used in antagonizing delayed cerebral vasospasm (dCVS), one of the main complications after subarachnoid hemorrhage (SAH), leading to delayed cerebral ischemia and ischemic neurological deficits. Data already exist that identified neuroprotective effects of levosimendan in a traumatic brain injury model and additionally, it has been proven that this compound prevents narrowing of the basilar artery (BA) luminal area after SAH in an in vitro rabbit model. Takotsubo cardiomyopathy, a severe ventricular dysfunction, is also a well-known complication after SAH, associated with pulmonary edema and prolonged intubation.

METHODS

The polypeptide endothelin-1 (ET-1) plays a key role in the development of dCVS after SAH. Therefore, the aim of the present investigation was to detect functional interactions between the calcium-sensitizing and the ET-1-dependent vasoconstriction after experimental-induced SAH; interactions between levosimendan and a substrate-specific vasorelaxation in the BA were also examined. It was reviewed whether levosimendan has a beneficial influence on endothelin(A) and/or endothelin(B₁) receptors (ET-(A) and ET-(B₁) receptors) in cerebral vessels after SAH. We also examined whether this drug could have antagonistic effects on a PGF-induced vasoconstriction.

RESULTS

Under treatment with levosimendan after SAH, the endothelin system seems to be affected. The ET-1-induced contraction is decreased, not significantly. In addition, we detected changes in the nitric oxide-cyclic guanosine monophosphate (NO-cGMP) pathway. Preincubation with levosimendan causes a modulatory effect on the ET-(B₁) receptor-dependent vasorelaxation. It induces an upregulation of the NO-cGMP pathway with a significantly increased relaxation. Even after PGF-induced precontraction a dose-dependent relaxation was registered, which was significantly higher (E_max) and earlier (pD₂) compared to the concentration-effect curve without levosimendan.

CONCLUSIONS

After experimental-induced dCVS, levosimendan seems to restore the well-known impaired function of the vasorelaxant ET-(B₁) receptor. Levosimendan also reversed the PGF-induced contraction dose-dependently. Both of these mechanisms could be used for antagonizing dCVS in patients suffering SAH. Levosimendan could even be used additionally in treating patients developing takotsubo cardiomyopathy.

Effects of levosimendan on heart failure in normotensive patients: does loading dose matter?

BACKGROUND

Levosimendan is a calcium sensitizer and K(+)-ATP channel opener with inotropic and vasodilatatory effects irrespective of myocardial oxygen consumption, used for treatment of heart failure (HF). A loading dose is usually given by infusion for 12 h; however, profound lowering of blood pressure often disrupts or prolongs the infusion. The aim of this study was to assess clinical, biochemical and myocardial differences between different regimes of levosimendan therapy, with or without loading dose, and compared to standard therapy in heart failure.

METHODS

Fifty-seven patients (mean age ± SD: 60.9 ± 9.3 years, 45 males) with HF, New York Heart Association (NYHA) III-IV, reduced left ventricular ejection fraction (LVEF) were included. Twenty patients (NB group) were given levosimendan without loading dose, 14 patients (B group) were given levosimendan with loading dose, and 23 patients (C group) were given standard therapy. Clinical, biochemical and echocardiographic characteristics at baseline and one week after treatment were evaluated.

RESULTS

Groups were similar at baseline. After one week NHYA class (P < 0.001), NT pro-BNP (P < 0.001), LVEF (P = 0.045), E/A (P = 0.048) E/e' (P < 0.001), and PAPs (P < 0.001) decreased. DT (P = 0.011) and TAPSE (P = 0.035) increased in all groups.

CONCLUSIONS

Levosimendan, as well as standard therapy, improves myocardial function and symptoms of HF, irrespective of the loading dose administration. Treatment options for patients with end-stage heart failure refractory to conventional medical therapy are limited. Inotropic drugs play an important role in heart failure (HF).

Effect of levosimendan on the short-term clinical course of patients with acutely decompensated heart failure

BACKGROUND

This study evaluated the efficacy and safety of levosimendan, a positive inotropic drug with vasodilator effects, given intravenously to patients with acutely decompensated heart failure (ADHF).

METHODS

We performed 2 sequential trials, the first to develop a new measure of efficacy in 100 patients, and the second to use this measure to evaluate levosimendan in an additional 600 patients. Patients admitted with ADHF received placebo or intravenous levosimendan for 24 h in addition to standard treatment. The primary endpoint was a composite that evaluated changes in clinical status during the first 5 days after randomization.

RESULTS

In the 600-patient trial, more levosimendan than placebo patients (58 vs. 44) were improved at all 3 pre-specified time points (6 h, 24 h, and 5 days), whereas fewer levosimendan patients (58 vs. 82) experienced clinical worsening (p = 0.015 for the difference between the groups). These differences were apparent, despite more frequent intensification of adjunctive therapy in the placebo group (79 vs. 45 patients). Improvements in patient self-assessment and declines in B-type natriuretic peptide levels with levosimendan persisted for 5 days and were associated with reduced length of stay (p = 0.009). Similar findings were present in the 100-patient pilot trial. Levosimendan was associated with more frequent hypotension and cardiac arrhythmias during the infusion period and a numerically higher risk of death across the 2 trials (49 of 350 on a regimen of levosimendan vs. 40 of 350 on a regimen of placebo at 90 days, p = 0.29).

CONCLUSIONS

In patients with ADHF, intravenous levosimendan provided rapid and durable symptomatic relief. As dosed in this trial, levosimendan was associated with an increased risk of adverse cardiovascular events. (Evaluation of Intravenous Levosimendan Efficacy in the Short Term Treatment of Decompensated Chronic Heart Failure; NCT00048425).

Heart failure after myocardial infarction: clinical implications and treatment

Heart failure is a frequent complication of myocardial infarction. Several factors, such as recurrent myocardial ischemia, infarct size, ventricular remodeling, stunned myocardium, mechanical complications, and hibernating myocardium influence the appearance of left ventricular systolic dysfunction after myocardial infarction. Importantly, its presence increases the risk of death by at least 3- to 4-fold. The knowledge of the mechanisms and clinical features are essential for the diagnosis and treatment of left ventricular dysfunction and heart failure after myocardial infarction. Therefore, this review will focus on the clinical implications and treatment of heart failure after myocardial infarction. © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.

Update on ventricular assist device management in the ICU

PURPOSE OF REVIEW

Mechanical circulatory support has a progressively increasing impact in the treatment of heart failure. The results of mechanical circulatory support are limited not only by the severity of the disease, which necessitated initiation of support, but also by the serious device-related adverse events. Optimized patient selection, improved patient management, and advanced device technology are interdependent key factors that contributed to the recently improved outcomes. The aim of this article is to summarize the current experience in application of mechanical circulatory support, focusing on the ICU management.

RECENT FINDINGS

Management should aim to prevent rather than treat serious complications and adverse events. Timing of intervention, optimization of the preimplantation patient status, patient and device management to ensure optimal hemodynamics, infection prevention, nutritional support, careful anticoagulation, and vigilance for early recognition and prompt treatment of 'minor' events before progression into major complications are essential elements of successful treatment.

SUMMARY

Critical patient care is a valuable adjunct to successful application of mechanical circulatory support, but it cannot counterbalance a late intervention, neither can it be fruitful in treating irreversible organ damage. Current management includes careful application of treatment protocols adjusted to recent experience, and also individualized care by a specialized team.