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Salvador VD, Bakris GL. Novel antihypertensive agents for resistant hypertension: what does the future hold? Hypertens Res 2022; 45:1918-1928. [PMID: 36167808 DOI: 10.1038/s41440-022-01025-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/16/2022] [Accepted: 08/25/2022] [Indexed: 11/09/2022]
Abstract
Finding complementary compelling novel therapeutic agents for better control of blood pressure in people with resistant hypertension is moving into unchartered territory. The latest therapeutic developments explore approaches in the clinical arena that were either not examined or could only be examined in animal models two decades ago. Four main mechanisms have now been explored and operationalized in drug development: (a) mineralocorticoid receptor blockade using a nonsteroidal structure with many fewer side effects, (b) an aminopeptidase A inhibitor that has central effects on vasopressin, (c) a combined endothelin A and B receptor blocker and (d) an aldosterone synthase inhibitor devoid of glucocorticoid activity. All these agents are either completing Phase II development and starting Phase III or are involved in the ongoing recruitment of Phase III trials. Additionally, novel agents use antisense inhibition to block angiotensinogen development in the liver. These agents are discussed only for completeness, as they are still in Phase II trial development. Last, another agent that was initially being developed as an antihypertensive and once the data were reviewed by the company clearly showed efficacy as a heart failure agent was sacubitril/valsartan, which was ultimately approved. However, there are some discussions about reinvigorating the quest for an indication for hypertension, although no such steps have been formally initiated.
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Affiliation(s)
- Vincent D Salvador
- Department of Medicine, Am Heart Assoc. Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, IL, USA
| | - George L Bakris
- Department of Medicine, Am Heart Assoc. Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, IL, USA.
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2
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Lin DS, Wang T, Buranakitjaroen P, Chen C, Cheng H, Chia YC, Sukonthasarn A, Tay JC, Teo BW, Turana Y, Wang J, Kario K. Angiotensin receptor neprilysin inhibitor as a novel antihypertensive drug: Evidence from Asia and around the globe. J Clin Hypertens (Greenwich) 2021; 23:556-567. [PMID: 33305531 PMCID: PMC8029571 DOI: 10.1111/jch.14120] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/17/2020] [Accepted: 11/19/2020] [Indexed: 02/07/2023]
Abstract
Hypertension is a worldwide epidemic that continues to grow, with a subset of patients responding poorly to current treatment available. This is especially relevant in Asia, which constitutes 61% of the global population. Hypertension in Asia is a unique entity that is often salt-sensitive, nocturnal, and systolic predominant. Sacubitril/valsartan is a first-in-class angiotensin receptor neprilysin inhibitor that was first used in heart failure with reduced ejection fraction. Sacubitril inhibits neprilysin, a metallopeptidase that degrades natriuretic peptides (NPs). NPs exert sympatholytic, diuretic, natriuretic, vasodilatory, and insulin-sensitizing effects mostly via cyclic guanosine monophosphate (cGMP)-mediated pathways. As an antihypertensive agent, sacubitril/valsartan has outperformed angiotensin II receptor type 1 blockers (ARBs), with additional reductions of office systolic blood pressures ranging between 5 and 7 mmHg, in multiple studies in Asia and around the globe. The drug was well tolerated even in the elderly or those with chronic kidney disease. Its mechanisms of actions are particularly attractive for treatment of hypertension in Asia. Sacubitril/valsartan offers a novel, dual class, single-molecule property that may be considered as first-line antihypertensive therapy. Further investigations are needed to validate its safety for long-term use and to explore other potentials such as in the management of insulin resistance and obesity, which often coexist with hypertension in Asia.
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Affiliation(s)
- Donna S.‐H. Lin
- Department of Internal MedicineCardiovascular Center and Division of CardiologyNational Taiwan University HospitalTaipei CityTaiwan
| | - Tzung‐Dau Wang
- Department of Internal MedicineCardiovascular Center and Division of CardiologyNational Taiwan University HospitalTaipei CityTaiwan
- Department of Internal MedicineDivision of Hospital MedicineNational Taiwan University HospitalTaipei CityTaiwan
| | - Peera Buranakitjaroen
- Department of MedicineDivision of HypertensionFaculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Chen‐Huan Chen
- Institute of Public Health and Community Medicine Research CenterNational Yang‐Ming University School of MedicineTaipeiTaiwan
- Department of MedicineDivision of CardiologyTaipei Veterans General HospitalTaipeiTaiwan
- Faculty of MedicineNational Yang‐Ming University School of MedicineTaipeiTaiwan
| | - Hao‐Min Cheng
- Institute of Public Health and Community Medicine Research CenterNational Yang‐Ming University School of MedicineTaipeiTaiwan
- Department of MedicineDivision of CardiologyTaipei Veterans General HospitalTaipeiTaiwan
- Faculty of MedicineNational Yang‐Ming University School of MedicineTaipeiTaiwan
- Department of Medical EducationCenter for Evidence‐based MedicineTaipei Veterans General HospitalTaipeiTaiwan
| | - Yook Chin Chia
- Department of Medical SciencesSchool of Healthcare and Medical SciencesSunway UniversityBandar SunwaySelangor Darul EhsanMalaysia
- Department of Primary Care MedicineFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Apichard Sukonthasarn
- Department of Internal MedicineCardiology DivisionFaculty of MedicineChiang Mai UniversityThailand
| | - Jam Chin Tay
- Department of General MedicineTan Tock Seng HospitalSingaporeSingapore
| | - Boon Wee Teo
- Department of MedicineDivision of NephrologyYong Loo Lin School of MedicineSingaporeSingapore
| | - Yuda Turana
- School of Medicine and Health SciencesAtma Jaya Catholic University of IndonesiaJakartaIndonesia
| | - Ji‐Guang Wang
- Department of HypertensionCentre for Epidemiological Studies and Clinical Trialsthe Shanghai Institute of HypertensionShanghai Key Laboratory of HypertensionRuijin HospitalShanghai Jiaotong University School of MedicineShanghaiChina
| | - Kazuomi Kario
- Department of MedicineDivision of Cardiovascular MedicineJichi Medical University School of MedicineTochigiJapan
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3
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Martins E Pereira G, S Duarte G, Katerenchuk V, Costa J, David C, Ferreira JJ, Pinto FJ, Caldeira D. Safety and tolerability of sacubitril-valsartan: a systematic review and meta-analysis. Expert Opin Drug Saf 2021; 20:577-588. [PMID: 33459086 DOI: 10.1080/14740338.2021.1877658] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Sacubitril-valsartan is a recently approved drug. However, there are few data regarding safety issues. We aimed to summarize the available evidence regarding sacubitril-valsartan's safety and tolerability.Methods: We conducted a systematic review with meta-analysis of randomized controlled trials (RCTs) enrolling patients receiving sacubitril-valsartan for any condition, compared with standard therapy or placebo. Database search was performed in October 2019. Outcomes were adverse events (AEs), serious AEs (SAEs), discontinuation due to AEs, and five AEs of special interest. Data were reported using risk ratio (RR) and 95% confidence interval (95%CI).Results: We included 20 RCTs (22510 participants). When compared with active controls, there were no differences in SAEs (RR=0.93, 95%CI 0.86-1.01) and AEs (RR=1.00, 95%CI 0.97-1.03). However, sacubitril-valsartan resulted in an 8% risk reduction in discontinuation due to AEs (95%CI 0.85-0.99) and an increased risk of hypotension (RR=1.45, 95%CI 1.27-1.67). The risk of angioedema was higher with follow-ups greater than 12 months (RR=2.36, 95%CI 1.29-4.33). There were no further significant differences in the remaining AEs' risk.Conclusions: Sacubitril-valsartan was at least as safe and tolerable as active control, with a similar need of administration cautiousness, except for a higher risk of hypotension. However, one should consider the study's limitations.
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Affiliation(s)
| | - Gonçalo S Duarte
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, Lisboa, Portugal.,Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa. Avenida Professor Egas Moniz, Lisboa, Portugal.,Faculdade de Medicina, Centro de Estudos de Medicina Baseada na Evidência, Universidade de Lisboa, Lisboa, Portugal
| | - Vasyl Katerenchuk
- Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, Lisboa, Portugal
| | - João Costa
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, Lisboa, Portugal.,Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa. Avenida Professor Egas Moniz, Lisboa, Portugal.,Faculdade de Medicina, Centro de Estudos de Medicina Baseada na Evidência, Universidade de Lisboa, Lisboa, Portugal
| | - Cláudio David
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, Lisboa, Portugal.,Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa. Avenida Professor Egas Moniz, Lisboa, Portugal.,Serviço de Cardiologia, Hospital Universitário de Santa Maria (CHULN), CAML, Centro Cardiovascular da Universidade de Lisboa - CCUL, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, Lisboa, Portugal
| | - Joaquim J Ferreira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, Lisboa, Portugal.,Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa. Avenida Professor Egas Moniz, Lisboa, Portugal.,CNS-Campus Neurológico Sénior, Torres Vedras, Portugal
| | - Fausto J Pinto
- Serviço de Cardiologia, Hospital Universitário de Santa Maria (CHULN), CAML, Centro Cardiovascular da Universidade de Lisboa - CCUL, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, Lisboa, Portugal
| | - Daniel Caldeira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, Lisboa, Portugal.,Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa. Avenida Professor Egas Moniz, Lisboa, Portugal.,Serviço de Cardiologia, Hospital Universitário de Santa Maria (CHULN), CAML, Centro Cardiovascular da Universidade de Lisboa - CCUL, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, Lisboa, Portugal
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4
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Leontsinis I, Mantzouranis M, Tsioufis P, Andrikou I, Tsioufis C. Recent advances in managing primary hypertension. Fac Rev 2020; 9:4. [PMID: 33659936 PMCID: PMC7894269 DOI: 10.12703/b/9-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Hypertension remains a leading risk factor for cardiovascular mortality and morbidity globally despite the availability of effective and well-tolerated antihypertensive medications. Accumulating evidence suggests a more aggressive blood pressure regulation aimed at lower targets, particularly for selected patient groups. Our concepts of the optimal method for blood pressure measurement have radically changed, maintaining appropriate standard office measurements for initial assessment but relying on out-of-office measurement to better guide our decisions. Thorough risk stratification provides guidance in decision making; however, an individualized approach is highly recommended to prevent overtreatment. Undertreatment, on the other hand, remains a major concern and is mainly attributed to poor adherence and resistant or difficult-to-control forms of the disease. This review aims to present modern perspectives, novel treatment options, including innovative technological applications and developing interventional and pharmaceutical therapies, and the major concerns emerging from several years of research and epidemiological observations related to hypertension management.
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Affiliation(s)
- Ioannis Leontsinis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 108 Vas. Sofias Ave, 11527, Athens, Greece
| | - Manos Mantzouranis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 108 Vas. Sofias Ave, 11527, Athens, Greece
| | - Panagiotis Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 108 Vas. Sofias Ave, 11527, Athens, Greece
| | - Ioannis Andrikou
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 108 Vas. Sofias Ave, 11527, Athens, Greece
| | - Costas Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 108 Vas. Sofias Ave, 11527, Athens, Greece
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5
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Wehland M, Simonsen U, Buus NH, Krüger M, Grimm D. An evaluation of the fixed-dose combination sacubitril/valsartan for the treatment of arterial hypertension. Expert Opin Pharmacother 2020; 21:1133-1143. [PMID: 32133873 DOI: 10.1080/14656566.2020.1735356] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Essential hypertension is a significant risk factor for cardiovascular disease, renal disease, and mortality with increasing prevalence. Despite the availability of various antihypertensive agents, hypertension is still poorly controlled. Therefore, new chemical compounds with antihypertensive efficacy need to be developed. The dual angiotensin II receptor-neprilysin inhibitor LCZ696 is a single molecule synthesized by co-crystallization of valsartan and the neprilysin inhibitor prodrug sacubitril (1:1 molar ratio). AREAS COVERED This review includes an overview of hypertension and the current pharmacotherapy. The authors summarize the LCZ696 drug chemistry, pharmacodynamics, pharmacokinetics, metabolism, randomized control trials (RCTs), and safety concerns. Databases searched included PubMed, Google Scholar, Embase, and ClinicalTrials.gov. EXPERT OPINION LCZ696 is effective in hypertension treatment. Short-term RCTs have shown that the highest doses of LCZ696 (200 and 400 mg [q.d.]) were more effective at lowering office and ambulatory blood pressure than angiotensin II receptor blockers (ARB) alone while having a similar tolerability profile. The effects of LCZ696 on hypertensive organ damage are only sparsely investigated and so far no studies have established the impact of LCZ696 on cardiovascular event rates. Future studies should focus on the comparison of LCZ696 and combination therapies already in use such as ARB and calcium channel blockers.
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Affiliation(s)
- Markus Wehland
- Department of Biomedicine, Aarhus University , Aarhus C, Denmark.,Clinic for Plastic, Aesthetic and Hand Surgery, Otto von Guericke University Magdeburg , Magdeburg, Germany
| | - Ulf Simonsen
- Department of Biomedicine, Aarhus University , Aarhus C, Denmark
| | - Niels Henrik Buus
- Department of Biomedicine, Aarhus University , Aarhus C, Denmark.,Department of Renal Medicine, Aarhus University Hospital , Aarhus, Denmark
| | - Marcus Krüger
- Clinic for Plastic, Aesthetic and Hand Surgery, Otto von Guericke University Magdeburg , Magdeburg, Germany
| | - Daniela Grimm
- Department of Biomedicine, Aarhus University , Aarhus C, Denmark.,Clinic for Plastic, Aesthetic and Hand Surgery, Otto von Guericke University Magdeburg , Magdeburg, Germany.,Department of Microgravity and Translational Regenerative Medicine, Faculty of Medicine and Mechanical Engineering, Otto von Guericke University , Magdeburg, Germany
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6
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Celik S, Sadegh MK, Morley M, Roselli C, Ellinor PT, Cappola T, Smith JG, Gidlöf O. Antisense regulation of atrial natriuretic peptide expression. JCI Insight 2019; 4:130978. [PMID: 31503546 DOI: 10.1172/jci.insight.130978] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/04/2019] [Indexed: 12/11/2022] Open
Abstract
The cardiac hormone atrial natriuretic peptide (ANP) is a central regulator of blood volume and a therapeutic target in hypertension and heart failure. Enhanced ANP activity in such conditions through inhibition of the degradative enzyme neprilysin has shown clinical efficacy but is complicated by consequences of simultaneous accumulation of a heterogeneous array of other hormones. Targets for specific ANP enhancement have not been available. Here, we describe a cis-acting antisense transcript (NPPA-AS1), which negatively regulates ANP expression in human cardiomyocytes. We show that NPPA-AS1 regulates ANP expression via facilitating NPPA repressor RE1-silencing transcription factor (REST) binding to its promoter, rather than forming an RNA duplex with ANP mRNA. Expression of ANP mRNA and NPPA-AS1 was increased and correlated in isolated strained human cardiomyocytes and in hearts from patients with advanced heart failure. Further, inhibition of NPPA-AS1 in vitro and in vivo resulted in increased myocardial expression of ANP, increased circulating ANP, increased renal cGMP, and lower blood pressure. The effects of NPPA-AS1 inhibition on NPPA expression in human cardiomyocytes were further marked under cell-strain conditions. Collectively, these results implicate the antisense transcript NPPA-AS1 as part of a physiologic self-regulatory ANP circuit and a viable target for specific ANP augmentation.
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Affiliation(s)
- Selvi Celik
- Department of Cardiology, Clinical Sciences.,Wallenberg Center for Molecular Medicine, and.,Lund University Diabetes Center, Lund University, Lund, Sweden
| | - Mardjaneh Karbalaei Sadegh
- Department of Cardiology, Clinical Sciences.,Wallenberg Center for Molecular Medicine, and.,Lund University Diabetes Center, Lund University, Lund, Sweden
| | - Michael Morley
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carolina Roselli
- Program in Medical and Population Genetics, The Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Patrick T Ellinor
- Program in Medical and Population Genetics, The Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA.,Cardiovascular Research Center and Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thomas Cappola
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J Gustav Smith
- Department of Cardiology, Clinical Sciences.,Wallenberg Center for Molecular Medicine, and.,Lund University Diabetes Center, Lund University, Lund, Sweden.,Program in Medical and Population Genetics, The Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA.,Department of Heart Failure and Valvular Heart Disease, Skane University Hospital, Lund, Sweden
| | - Olof Gidlöf
- Department of Cardiology, Clinical Sciences.,Wallenberg Center for Molecular Medicine, and.,Lund University Diabetes Center, Lund University, Lund, Sweden
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7
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Manolis AS, Manolis TA, Manolis AA, Melita H. Neprilysin Inhibitors: Filling a Gap in Heart Failure Management, Albeit Amidst Controversy and at a Significant Cost. Am J Cardiovasc Drugs 2019; 19:21-36. [PMID: 29926350 DOI: 10.1007/s40256-018-0289-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Dual angiotensin and neprilysin inhibition using the combination drug sacubitril-valsartan has ushered in a new era in the treatment of heart failure (HF). The randomized controlled PARADIGM-HF trial, which randomized 8399 patients with HF to enalapril or sacubitril-valsartan, showed a 20% reduction in mortality and HF hospitalization with the new drug. This has been heralded as a step toward filling a crucial gap in HF management by providing strong evidence that combined inhibition of the angiotensin receptor and neprilysin is superior to inhibition of the renin-angiotensin system alone in stable patients with chronic HF as it negates the deleterious effects of angiotensin while concomitantly augmenting the beneficial effects of the endogenous natriuretic peptide system. This new therapy is costly, and other confirmatory studies have been lacking for over 2 years since its approval by major regulatory authorities. As such, controversy and heated discussions have amassed, as has detailed information from a plethora of secondary analyses of this pivotal trial about the pros and cons of this promising new therapeutic strategy in HF management. The aim of this review was to provide a critical assessment of all these aspects.
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Affiliation(s)
- Antonis S Manolis
- Third Department of Cardiology, Athens University School of Medicine, Vas. Sofias 114, 115 27, Athens, Greece.
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