1
|
Gallo G, Volpe M. Potential Mechanisms of the Protective Effects of the Cardiometabolic Drugs Type-2 Sodium-Glucose Transporter Inhibitors and Glucagon-like Peptide-1 Receptor Agonists in Heart Failure. Int J Mol Sci 2024; 25:2484. [PMID: 38473732 DOI: 10.3390/ijms25052484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/16/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
Different multifactorial pathophysiological processes are involved in the development of heart failure (HF), including neurohormonal dysfunction, the hypertrophy of cardiomyocytes, interstitial fibrosis, microvascular endothelial inflammation, pro-thrombotic states, oxidative stress, decreased nitric oxide (NO) bioavailability, energetic dysfunction, epicardial coronary artery lesions, coronary microvascular rarefaction and, finally, cardiac remodeling. While different pharmacological strategies have shown significant cardiovascular benefits in HF with reduced ejection fraction (HFrEF), there is a residual unmet need to fill the gap in terms of knowledge of mechanisms and efficacy in the outcomes of neurohormonal agents in HF with preserved ejection fraction (HFpEF). Recently, type-2 sodium-glucose transporter inhibitors (SGLT2i) have been shown to contribute to a significant reduction in the composite outcome of HF hospitalizations and cardiovascular mortality across the entire spectrum of ejection fraction. Moreover, glucagon-like peptide-1 receptor agonists (GLP1-RA) have demonstrated significant benefits in patients with high cardiovascular risk, excess body weight or obesity and HF, in particular HFpEF. In this review, we will discuss the biological pathways potentially involved in the action of SGLT2i and GLP1-RA, which may explain their effective roles in the treatment of HF, as well as the potential implications of the use of these agents, also in combination therapies with neurohormonal agents, in the clinical practice.
Collapse
Affiliation(s)
- Giovanna Gallo
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Via di Grottarossa 1035-1039, 00189 Rome, Italy
| | - Massimo Volpe
- IRCCS San Raffaele Roma, Via della Pisana 235, 00163 Rome, Italy
| |
Collapse
|
2
|
Kociánová E. Why take organ damage in hypertension seriously? VNITRNI LEKARSTVI 2022; 68:303-308. [PMID: 36283821 DOI: 10.36290/vnl.2022.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The focus of recent European guidelines has been early initiation of antihypertensive therapy in risk groups, rapid achievement of target blood pressure with fixed combinations of antihypertensive drugs, and the best possible management of an individuals cardiovascular risk. Early intervention in the development of hypertension-mediated organ damage (HMOD) has been shown to have an effect on the subsequent reduction in the risk of cardiovascular events. The point of HMOD origination correlates with the magnitude and duration of blood pressure elevation, and there is no clearly defined boundary from which vascular damage begins to develop. A reduction in blood pressure with pharmacotherapy demonstrably decreases the risk of ischaemic heart disease, stroke, as well as the mortality rate (1). Large clinical trials have consistently shown a significant reduction in the risk of these complications with antihypertensive medications across the entire spectrum from mild to severe hypertension, including hypertension in the elderly as well as isolated systolic hypertension (2). Based on the latest knowledge, a reduction in blood pressure by a mere 5 mm Hg has a cardioprotective effect even in normotensive individuals, which fundamentally changes the view on the diagnosis and definition of hypertension as a disease (3).
Collapse
|
3
|
Seko Y, Kato T, Yamaji Y, Haruna Y, Nakane E, Haruna T, Inoko M. Discrepancy between left ventricular hypertrophy by echocardiography and electrocardiographic hypertrophy: clinical characteristics and outcomes. Open Heart 2021; 8:openhrt-2021-001765. [PMID: 34556560 PMCID: PMC8461736 DOI: 10.1136/openhrt-2021-001765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/07/2021] [Indexed: 11/06/2022] Open
Abstract
Background The clinical significance of the discrepancy between left ventricular hypertrophy (LVH) by echocardiography and ECG remains to be elucidated. Methods After excluding patients who presented with pacemaker placement, QRS duration ≥120 ms and cardiomyopathy and moderate to severe valvular disease, we retrospectively analysed 3212 patients who had undergone both scheduled transthoracic echocardiography (echo) and ECG in a hospital-based population. Cornell product >2440 mm · ms was defined as ECG-based LVH; left ventricular mass index >115 g/m2 for men and >95 g/m2 for women was defined as echo-based LVH. The study population was categorised into four groups: patients with both ECG-based and echo-based LVH (N=131, 4.1%), those with only echo-based LVH (N=156, 4.9%), those with only ECG-based LVH (N=409, 12.7%) and those with no LVH (N=2516, 78.3%). Results The cumulative 3-year incidences of a composite of all-cause death and major adverse cardiovascular events were 32.0%, 33.8%, 19.2% and 15.7%, respectively. After adjusting for confounders, the HRs relative to that in no LVH were 1.63 (95% CI 1.16 to 2.28), 1.68 (95% CI 1.23 to 2.30) and 1.09 (95% CI 0.85 to 1.41) in patients with both ECG-based and echo-based LVH, those with only echo-based LVH, and those with only ECG-based LVH, respectively. Conclusions Echo-based LVH without ECG-based LVH was associated with a significant risk of adverse clinical events, and the risk was comparable to that in patients with both echo-based and ECG-based LVH.
Collapse
Affiliation(s)
- Yuta Seko
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuhei Yamaji
- Cardiovascular Center, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Yoshisumi Haruna
- Cardiovascular Center, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Eisaku Nakane
- Cardiovascular Center, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Tetsuya Haruna
- Cardiovascular Center, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Moriaki Inoko
- Cardiovascular Center, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| |
Collapse
|
4
|
Hypertension and heart failure with preserved ejection fraction: position paper by the European Society of Hypertension. J Hypertens 2021; 39:1522-1545. [PMID: 34102660 DOI: 10.1097/hjh.0000000000002910] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Hypertension constitutes a major risk factor for heart failure with preserved ejection fraction (HFpEF). HFpEF is a prevalent clinical syndrome with increased cardiovascular morbidity and mortality. Specific guideline-directed medical therapy (GDMT) for HFpEF is not established due to lack of positive outcome data from randomized controlled trials (RCTs) and limitations of available studies. Although available evidence is limited, control of blood pressure (BP) is widely regarded as central to the prevention and clinical care in HFpEF. Thus, in current guidelines including the 2018 European Society of Cardiology (ESC) and European Society of Hypertension (ESH) Guidelines, blockade of the renin-angiotensin system (RAS) with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers provides the backbone of BP-lowering therapy in hypertensive patients. Although superiority of RAS blockers has not been clearly shown in dedicated RCTs designed for HFpEF, we propose that this core drug treatment strategy is also applicable for hypertensive patients with HFpEF with the addition of some modifications. The latter apply to the use of spironolactone apart from the treatment of resistant hypertension and the use of the angiotensin receptor neprilysin inhibitor. In addition, novel agents such as sodium-glucose co-transporter-2 inhibitors, currently already indicated for high-risk patients with diabetes to reduce heart failure hospitalizations, and finerenone represent promising therapies and results from ongoing RCTs are eagerly awaited. The development of an effective and practical classification of HFpEF phenotypes and GDMT through dedicated high-quality RCTs are major unmet needs in hypertension research and calls for action.
Collapse
|
5
|
Nikolaidou T, Samuel NA, Marincowitz C, Fox DJ, Cleland JGF, Clark AL. Electrocardiographic characteristics in patients with heart failure and normal ejection fraction: A systematic review and meta-analysis. Ann Noninvasive Electrocardiol 2019; 25:e12710. [PMID: 31603593 PMCID: PMC7358891 DOI: 10.1111/anec.12710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 09/03/2019] [Accepted: 09/11/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Little is known about ECG abnormalities in patients with heart failure and normal ejection fraction (HeFNEF) and how they relate to different etiologies or outcomes. METHODS AND RESULTS We searched the literature for peer-reviewed studies describing ECG abnormalities in HeFNEF other than heart rhythm alone. Thirty five studies were identified and 32,006 participants. ECG abnormalities reported in patients with HeFNEF include atrial fibrillation (prevalence 12%-46%), long PR interval (11%-20%), left ventricular hypertrophy (LVH, 10%-30%), pathological Q waves (11%-18%), RBBB (6%-16%), LBBB (0%-8%), and long JTc (3%-4%). Atrial fibrillation is more common in patients with HeFNEF compared to those with heart failure and reduced ejection fraction (HeFREF). In contrast, long PR interval, LVH, Q waves, LBBB, and long JTc are more common in patients with HeFREF. A pooled effect estimate analysis showed that QRS duration ≥120 ms, although uncommon (13%-19%), is associated with worse outcomes in patients with HeFNEF. CONCLUSIONS There is high variability in the prevalence of ECG abnormalities in patients with HeFNEF. Atrial fibrillation is more common in patients with HeFNEF compared to those with HeFREF. QRS duration ≥120 ms is associated with worse outcomes in patients with HeFNEF. Further studies are needed to address whether ECG abnormalities correlate with different phenotypes in HeFNEF.
Collapse
Affiliation(s)
- Theodora Nikolaidou
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Nathan A Samuel
- Department of Academic Cardiology, Castle Hill Hospital, University of Hull, Hull, UK
| | - Carl Marincowitz
- Hull York Medical School, University of Hull, University of York, York, UK
| | - David J Fox
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK.,National Heart & Lung Institute and National Institute of Health Research Cardiovascular Biomedical Research Unit, Imperial College, Royal Brompton & Harefield Hospitals, London, UK
| | - Andrew L Clark
- Department of Academic Cardiology, Castle Hill Hospital, University of Hull, Hull, UK
| |
Collapse
|
6
|
Yang H, Marwick TH, Wang Y, Nolan M, Negishi K, Khan F, Okin PM. Association between electrocardiographic and echocardiographic markers of stage B heart failure and cardiovascular outcome. ESC Heart Fail 2017; 4:417-431. [PMID: 29154431 PMCID: PMC5695163 DOI: 10.1002/ehf2.12151] [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: 11/27/2016] [Revised: 02/02/2017] [Accepted: 02/16/2017] [Indexed: 12/28/2022] Open
Abstract
AIMS The detection of non-ischaemic (mainly hypertension, diabetes, and obesity) stage B heart failure (SBHF) may facilitate the recognition of those at risk of progression to overt HF and HF prevention. We sought the relationship of specific electrocardiographic (ECG) markers of SBHF to echocardiographic features of SBHF and their prognostic value for development of HF. The ECG markers were Cornell product (Cornell-P), P-wave terminal force in lead V1 (PTFV1), ST depression in lead V5 V6 (minSTmV5V6), and increased heart rate. Echocardiographic assessment of SBHF included left ventricular hypertrophy (LVH), impaired global longitudinal strain (GLS), and diastolic dysfunction (DD). METHOD AND RESULTS Asymptomatic subjects ≥65 years without prior cardiac history, but with HF risks, were recruited from the local community. At baseline, they underwent clinical assessment, 12-lead ECG, and comprehensive echocardiography. New HF was assessed clinically at mean follow-up of 14 ± 4 months, and echocardiography was repeated in subjects with HF. Of the 447 study subjects (age 71 ± 5, 47% men) with SBHF, 13% had LVH, 32% impaired GLS, and 65% ≥grade I DD (10% ≥grade II DD). Forty were lost to follow-up. Clinical HF developed in 47 of 407, of whom 20% had echocardiographic LVH, 51% abnormal GLS, and 76% DD at baseline. Baseline LVH and abnormal GLS (not grade I DD) were independently associated with outcomes (clinical HF and cardiovascular death). Cornell-P and heart rate (not minSTmV5V6 nor PTFV1) were independently associated with LVH, impaired GLS, and DD. Cornell-P and minSTV5V6 (not heart rate nor PTFV1) were independently associated with outcomes. More ECG abnormalities improved sensitivity, but ECG-markers were not independent of or incremental to echocardiographic markers to predict HF in SBHF. CONCLUSIONS In this elderly study population, ECG markers showed low diagnostic sensitivity for non-ischaemic SBHF and low prognostic value for outcomes. Cornell-P and minSTmV5V6 had predictive value for outcomes in non-ischaemic SBHF independent of age, gender, and common comorbidities but were not incremental to echocardiography.
Collapse
Affiliation(s)
- Hong Yang
- Menzies Institute for Medical ResearchHobartAustralia
| | - Thomas H. Marwick
- Menzies Institute for Medical ResearchHobartAustralia
- Baker‐IDI Heart and Diabetes InstituteMelbourneAustralia
| | - Ying Wang
- Menzies Institute for Medical ResearchHobartAustralia
| | - Mark Nolan
- Menzies Institute for Medical ResearchHobartAustralia
| | | | | | - Peter M. Okin
- Division of Cardiology, Department of MedicineWeill Medical College of Cornell UniversityNew YorkNYUSA
| |
Collapse
|
7
|
Tanoue MT, Kjeldsen SE, Devereux RB, Okin PM. Relationship of diastolic function to new or persistent electrocardiographic left ventricular hypertrophy. Blood Press 2016; 25:364-372. [DOI: 10.1080/08037051.2016.1179514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Michael T. Tanoue
- Greenberg Division of Cardiology, Weill Cornell Medical College, New York, NY, USA
| | - Sverre E. Kjeldsen
- Ullevål Hospital, Oslo, Norway and University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Richard B. Devereux
- Greenberg Division of Cardiology, Weill Cornell Medical College, New York, NY, USA
| | - Peter M. Okin
- Greenberg Division of Cardiology, Weill Cornell Medical College, New York, NY, USA
| |
Collapse
|