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Markousis-Mavrogenis G, Baumhove L, Al-Mubarak AA, Aboumsallem JP, Bomer N, Voors AA, van der Meer P. Immunomodulation and immunopharmacology in heart failure. Nat Rev Cardiol 2024; 21:119-149. [PMID: 37709934 DOI: 10.1038/s41569-023-00919-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/16/2023]
Abstract
The immune system is intimately involved in the pathophysiology of heart failure. However, it is currently underused as a therapeutic target in the clinical setting. Moreover, the development of novel immunomodulatory therapies and their investigation for the treatment of patients with heart failure are hampered by the fact that currently used, evidence-based treatments for heart failure exert multiple immunomodulatory effects. In this Review, we discuss current knowledge on how evidence-based treatments for heart failure affect the immune system in addition to their primary mechanism of action, both to inform practising physicians about these pleiotropic actions and to create a framework for the development and application of future immunomodulatory therapies. We also delineate which subpopulations of patients with heart failure might benefit from immunomodulatory treatments. Furthermore, we summarize completed and ongoing clinical trials that assess immunomodulatory treatments in heart failure and present several therapeutic targets that could be investigated in the future. Lastly, we provide future directions to leverage the immunomodulatory potential of existing treatments and to foster the investigation of novel immunomodulatory therapeutics.
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Affiliation(s)
- George Markousis-Mavrogenis
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Lukas Baumhove
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ali A Al-Mubarak
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Joseph Pierre Aboumsallem
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Nils Bomer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
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Li J, Zhu Y, Zhao X, Zhao L, Wang Y, Yang Z. Screening of anti-heart failure active compounds from fangjihuangqi decoction in verapamil-induced zebrafish model by anti-heart failure index approach. Front Pharmacol 2022; 13:999950. [PMID: 36278179 PMCID: PMC9585168 DOI: 10.3389/fphar.2022.999950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/22/2022] [Indexed: 11/14/2022] Open
Abstract
Heart failure is the end stage of various cardiovascular diseases. Fangjihuangqi Decoction (FJHQD) is a famous traditional Chinese medicine (TCM) formula, which is clinically effective in the treatment of chronic heart failure. However, the anti-heart failure ingredients of FJHQD have not been clarified, and the related mechanisms of action are rarely studied. In the present study, through quantification analysis of heart rate and ventricular area changes, a heart failure model and cardiac function evaluation system in cardiomyocytes-labelled Tg (cmlc2: eGFP) transgenic zebrafish larvae were constructed, and the anti-heart failure index (AHFI) that can comprehensively evaluate the cardiac function of zebrafish was proposed. Based on this model, FJHQD, its mainly botanical drugs, components and ingredients were evaluated for the anti-heart failure effects. The results showed that FJHQD and its botanical drugs exhibited potent anti-heart failure activity. Furthermore, total alkaloids from Stephania tetrandra S. Moore, total flavonoids from Astragalus mongholicus Bunge and total flavonoids from Glycyrrhiza uralensis Fisch. ex DC. were identified to be the main components exerting the anti-heart failure activity of FJHQD. Then, we screened the main ingredients of these components, and glycyrrhizic acid, licochalcone A and calycosin were found to exhibit excellent cardioprotective effects. Finally, we found that FJHQD, glycyrrhizic acid, licochalcone A and calycosin may improve cardiac function in zebrafish by regulating oxidative stress, inflammatory response and apoptosis-related pathways. Taken together, our findings offer biological evidences toward the anti-heart failure effect of FJHQD, and provide guidance for the clinical application of FJHQD.
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Affiliation(s)
- Jun Li
- Pharmaceutical Informatics Institute, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Yue Zhu
- Pharmaceutical Informatics Institute, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Xiaoping Zhao
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
- *Correspondence: Zhenzhong Yang, ; Xiaoping Zhao,
| | - Lu Zhao
- Pharmaceutical Informatics Institute, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
- Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, Hangzhou, China
| | - Yi Wang
- Pharmaceutical Informatics Institute, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
- Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, Hangzhou, China
- Jinhua Institute of Zhejiang University, Jinhua, China
- Innovation Center in Zhejiang University, State Key Laboratory of Component-Based Chinese Medicine, Hangzhou, China
| | - Zhenzhong Yang
- Pharmaceutical Informatics Institute, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
- Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, Hangzhou, China
- Jinhua Institute of Zhejiang University, Jinhua, China
- Innovation Center in Zhejiang University, State Key Laboratory of Component-Based Chinese Medicine, Hangzhou, China
- *Correspondence: Zhenzhong Yang, ; Xiaoping Zhao,
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3
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Zhou L, Sun J, Gu L, Wang S, Yang T, Wei T, Shan T, Wang H, Wang L. Programmed Cell Death: Complex Regulatory Networks in Cardiovascular Disease. Front Cell Dev Biol 2021; 9:794879. [PMID: 34901035 PMCID: PMC8661013 DOI: 10.3389/fcell.2021.794879] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/15/2021] [Indexed: 12/25/2022] Open
Abstract
Abnormalities in programmed cell death (PCD) signaling cascades can be observed in the development and progression of various cardiovascular diseases, such as apoptosis, necrosis, pyroptosis, ferroptosis, and cell death associated with autophagy. Aberrant activation of PCD pathways is a common feature leading to excessive cardiac remodeling and heart failure, involved in the pathogenesis of various cardiovascular diseases. Conversely, timely activation of PCD remodels cardiac structure and function after injury in a spatially or temporally restricted manner and corrects cardiac development similarly. As many cardiovascular diseases exhibit abnormalities in PCD pathways, drugs that can inhibit or modulate PCD may be critical in future therapeutic strategies. In this review, we briefly describe the process of various types of PCD and their roles in the occurrence and development of cardiovascular diseases. We also discuss the interplay between different cell death signaling cascades and summarize pharmaceutical agents targeting key players in cell death signaling pathways that have progressed to clinical trials. Ultimately a better understanding of PCD involved in cardiovascular diseases may lead to new avenues for therapy.
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Affiliation(s)
- Liuhua Zhou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jiateng Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lingfeng Gu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Sibo Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Tongtong Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Tianwen Wei
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Tiankai Shan
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hao Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Liansheng Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Role of Myocardial Infarction-Induced Neuroinflammation for Depression-Like Behavior and Heart Failure in Ovariectomized Female Rats. Neuroscience 2019; 415:201-214. [DOI: 10.1016/j.neuroscience.2019.07.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/04/2019] [Accepted: 07/05/2019] [Indexed: 12/20/2022]
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Ayoub KF, Pothineni NVK, Rutland J, Ding Z, Mehta JL. Immunity, Inflammation, and Oxidative Stress in Heart Failure: Emerging Molecular Targets. Cardiovasc Drugs Ther 2018; 31:593-608. [PMID: 28956198 DOI: 10.1007/s10557-017-6752-z] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Heart failure (HF) remains a major cause of morbidity and mortality worldwide. Although various therapies developed over the last two decades have shown improved long term outcomes in patients with established HF, there has been little progress in preventing the adverse cardiac remodeling that initiates HF. To fill the gap in treatment, current research efforts are focused on understanding novel mechanisms and signaling pathways. Immune activation, inflammation, oxidative stress, alterations in mitochondrial bioenergetics, and autophagy have been postulated as important pathophysiological events in this process. An improved understanding of these complex processes could facilitate a therapeutic shift toward molecular targets that can potentially alter the course of HF. METHODS In this review, we address the role of immunity, inflammation, and oxidative stress as well as other novel emerging concepts in the pathophysiology of HF that may have therapeutic implications. CONCLUSION Based on the experimental and clinical studies presented here, we anticipate that a better understanding of the pathophysiology of HF will open the door for new therapeutic targets. A one-size-fits-all approach may not be appropriate for all patients with HF, and further clinical trials utilizing molecular targeting in HF may result in improved outcomes.
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Affiliation(s)
- Karam F Ayoub
- Division of Cardiology, Central Arkansas Veterans Healthcare System and the University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Naga Venkata K Pothineni
- Division of Cardiology, Central Arkansas Veterans Healthcare System and the University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Joshua Rutland
- Division of Cardiology, Central Arkansas Veterans Healthcare System and the University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Zufeng Ding
- Division of Cardiology, Central Arkansas Veterans Healthcare System and the University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jawahar L Mehta
- Division of Cardiology, Central Arkansas Veterans Healthcare System and the University of Arkansas for Medical Sciences, Little Rock, AR, USA. .,Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, #532, Little Rock, AR, 72205, USA.
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6
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Jahng JWS, Song E, Sweeney G. Crosstalk between the heart and peripheral organs in heart failure. Exp Mol Med 2016; 48:e217. [PMID: 26964833 PMCID: PMC4892881 DOI: 10.1038/emm.2016.20] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 12/10/2015] [Accepted: 12/11/2015] [Indexed: 12/31/2022] Open
Abstract
Mediators from peripheral tissues can influence the development and progression of heart failure (HF). For example, in obesity, an altered profile of adipokines secreted from adipose tissue increases the incidence of myocardial infarction (MI). Less appreciated is that heart remodeling releases cardiokines, which can strongly impact various peripheral tissues. Inflammation, and, in particular, activation of the nucleotide-binding oligomerization domain-like receptors with pyrin domain (NLRP3) inflammasome are likely to have a central role in cardiac remodeling and mediating crosstalk with other organs. Activation of the NLRP3 inflammasome in response to cardiac injury induces the production and secretion of the inflammatory cytokines interleukin (IL)-1β and IL-18. In addition to having local effects in the myocardium, these pro-inflammatory cytokines are released into circulation and cause remodeling in the spleen, kidney, skeletal muscle and adipose tissue. The collective effects of various cardiokines on peripheral organs depend on the degree and duration of myocardial injury, with systematic inflammation and peripheral tissue damage observed as HF progresses. In this article, we review mechanisms regulating myocardial inflammation in HF and the role of factors secreted by the heart in communication with peripheral tissues.
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Affiliation(s)
| | - Erfei Song
- Department of Biology, York University, Toronto, ON, Canada
| | - Gary Sweeney
- Department of Biology, York University, Toronto, ON, Canada
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Central nervous system circuits modified in heart failure: pathophysiology and therapeutic implications. Heart Fail Rev 2015; 19:759-79. [PMID: 24573960 DOI: 10.1007/s10741-014-9427-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The pathophysiology of heart failure (HF) is characterized by an abnormal activation of neurohumoral systems, including the sympathetic nervous and the renin-angiotensin-aldosterone systems, which have long-term deleterious effects on the disease progression. Perpetuation of this neurohumoral activation is partially dependent of central nervous system (CNS) pathways, mainly involving the paraventricular nucleus of the hypothalamus and some regions of the brainstem. Modifications in these integrative CNS circuits result in the attenuation of sympathoinhibitory and exacerbation of sympathoexcitatory pathways. In addition to the regulation of sympathetic outflow, these central pathways coordinate a complex network of agents with an established pathophysiological relevance in HF such as angiotensin, aldosterone, and proinflammatory cytokines. Central pathways could be potential targets in HF therapy since the current mainstay of HF pharmacotherapy aims primarily at antagonizing the peripheral mechanisms. Thus, in the present review, we describe the role of CNS pathways in HF pathophysiology and as potential novel therapeutic targets.
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Abstract
Elevated levels of inflammatory mediators have been identified in patients with heart failure, including heart failure with reduced and preserved ejection fraction, as well as acute decompensated heart failure. Moreover, experimental studies have shown repeatedly that activation of inflammation in the heart provokes left ventricular remodeling and left ventricular dysfunction. Nonetheless, phase III clinical trials that have attempted to antagonize inflammatory mediators have been negative with respect to the primary end points of the trials, and in some patients, resulted in worsening heart failure or death. The following review will discuss how recent developments in the field of innate immunity have advanced our understanding of the role of inflammation in the pathogenesis of heart failure and will discuss the negative outcomes of the existing clinical trials in light of this new information.
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Affiliation(s)
- Douglas L Mann
- From the Division of Cardiology, Department of Medicine, Center for Cardiovascular Research, Washington University School of Medicine, St. Louis, MO.
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9
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Lee YR, Kang MH, Park HM. Anthracycline-induced cardiomyopathy in a dog treated with epirubicin. THE CANADIAN VETERINARY JOURNAL = LA REVUE VETERINAIRE CANADIENNE 2015; 56:571-574. [PMID: 26028676 PMCID: PMC4431152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
An 8-year-old American cocker spaniel dog was diagnosed with dilated cardiomyopathy. Four years earlier, the dog had been diagnosed with multicentric lymphoma and had received 4 cycles of multi-agent chemotherapy, including doxorubicin and epirubicin. The total cumulative dose of epirubicin was 168 mg/m(2). Dilated cardiomyopathy was considered a consequence of epirubicin toxicity.
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Affiliation(s)
| | | | - Hee-Myung Park
- Address all correspondence to Dr. Hee-Myung Park; e-mail:
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10
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Champion S, Lapidus N, Cherié G, Spagnoli V, Oliary J, Solal AC. Pentoxifylline in heart failure: a meta-analysis of clinical trials. Cardiovasc Ther 2015; 32:159-62. [PMID: 24758396 DOI: 10.1111/1755-5922.12076] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Pentoxifylline possess antiinflammatory and rheological properties and has been tested in heart failure (HF). METHODS A comprehensive search was performed from 1980 until July 2013 in PubMed, to identify randomized controlled trials evaluating pentoxifylline versus placebo in HF, to determine impact on mortality. Search strategy is as follows: "Pentoxifylline" AND "heart" AND "trial". Study selection of six randomized controlled trials evaluating mortality as outcome. Then, we conducted a meta-analysis of randomized controlled trials versus placebo in HF. Determination of Mantel-Haenszel fixed effect and random-effect pooled odds ratios for all-cause mortality and corresponding 95% confidence intervals. RESULTS Data from a total of 221 patients with LVEF ≤40% from six randomized controlled trials were included in this analysis. Pentoxifylline 1200 mg per day was administered during 6 months, except in one study (administered during 1 month for severe acute HF). The use of pentoxifylline was not significantly associated with a reduction in mortality in HF in individual studies. The pooled data including 221 patients showed a nearly fourfold reduction in mortality (5.4% vs. 18.3%; OR 0.29; CI 0.12-0.74; P < 0.01) with homogenous results (I² 0%). CONCLUSION A meta-analysis evaluating pentoxifylline versus placebo in HF suggested a significant nearly fourfold decrease in all-cause mortality in the pentoxifylline group.
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Affiliation(s)
- Sébastien Champion
- Réanimation Médicale et Toxicologique, Hôpital Lariboisière, Paris, France
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11
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Glezeva N, Gallagher J, Ledwidge M, O'Donoghue J, McDonald K, Chipolombwe J, Watson C. Heart failure in sub-Saharan Africa: review of the aetiology of heart failure and the role of point-of-care biomarker diagnostics. Trop Med Int Health 2015; 20:581-588. [DOI: 10.1111/tmi.12461] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Nadezhda Glezeva
- gHealth Research Group; UCD Conway Institute of Biomolecular and Biomedical Research; University College Dublin; Dublin Ireland
| | - Joe Gallagher
- gHealth Research Group; UCD Conway Institute of Biomolecular and Biomedical Research; University College Dublin; Dublin Ireland
| | - Mark Ledwidge
- gHealth Research Group; UCD Conway Institute of Biomolecular and Biomedical Research; University College Dublin; Dublin Ireland
| | | | - Kenneth McDonald
- gHealth Research Group; UCD Conway Institute of Biomolecular and Biomedical Research; University College Dublin; Dublin Ireland
| | | | - Chris Watson
- gHealth Research Group; UCD Conway Institute of Biomolecular and Biomedical Research; University College Dublin; Dublin Ireland
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12
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Hofmann U, Frantz S. How can we cure a heart "in flame"? A translational view on inflammation in heart failure. Basic Res Cardiol 2013; 108:356. [PMID: 23740214 PMCID: PMC3709073 DOI: 10.1007/s00395-013-0356-y] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 04/03/2013] [Accepted: 04/08/2013] [Indexed: 01/12/2023]
Abstract
The prevalence of chronic heart failure is still increasing making it a major health issue in the 21st century. Tremendous evidence has emerged over the past decades that heart failure is associated with a wide array of mechanisms subsumed under the term “inflammation”. Based on the great success of immuno-suppressive treatments in auto-immunity and transplantation, clinical trials were launched targeting inflammatory mediators in patients with chronic heart failure. However, they widely lacked positive outcomes. The failure of the initial study program directed against tumor necrosis factor-α led to the search for alternative therapeutic targets involving a broader spectrum of mechanisms besides cytokines. We here provide an overview of the current knowledge on immune activation in chronic heart failure of different etiologies, summarize clinical studies in the field, address unresolved key questions, and highlight some promising novel therapeutic targets for clinical trials from a translational basic science and clinical perspective.
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Affiliation(s)
- Ulrich Hofmann
- Department of Internal Medicine I, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany.
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Falase AO, Ogah OS. Cardiomyopathies and myocardial disorders in Africa: present status and the way forward. Cardiovasc J Afr 2013. [PMID: 23192260 PMCID: PMC3721909 DOI: 10.5830/cvja-2012-046] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Abstract A review of heart diseases in Africa shows that the cardiomyopathies continue to be important causes of morbidity and mortality in the population. Hypertension remains the commonest cause of myocardial disease, followed by the cardiomyopathies. Ischaemic heart disease continues to be rare. Of the cardiomyopathies, dilated cardiomyopathy (DCM) is still the commonest. A large proportion of patients diagnosed with DCM in Africa have been shown to be cases of hypertensive heart failure, with varying degrees of myocardial dysfunction. Hypertrophic cardiomyopathy, which in the past was thought to be rare among Africans, has been shown to have the same prevalence as in other parts of the world. Moreover it is now known to be a genetic disorder. Endomyocardial fibrosis has become rare in communities where it used to be common. Its aetiology continues to be elusive. Arrhythmogenic right ventricular cardiomyopathy has been reported among Africans but there are no reports of left ventricular non-compaction or the ion channelopathies from Africa. Lenegre disease and the long-QT syndromes are well-known entities in clinical practice in Africa although long-QT in Africa is associated with potassium deficiency arising from prolonged treatment with diuretics. Left ventricular non-ischaemic aneurysms still occur but are rare. In view of these, a new classification of myocardial disorders was proposed for Africa.
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Affiliation(s)
- A O Falase
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria.
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14
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Falase AO, Ogah OS. Cardiomyopathies and myocardial disorders in Africa: present status and the way forward. Cardiovasc J Afr 2013. [PMID: 23192260 DOI: 10.5830/cvja-2012-046.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A review of heart diseases in Africa shows that the cardiomyopathies continue to be important causes of morbidity and mortality in the population. Hypertension remains the commonest cause of myocardial disease, followed by the cardiomyopathies. Ischaemic heart disease continues to be rare. Of the cardiomyopathies, dilated cardiomyopathy (DCM) is still the commonest. A large proportion of patients diagnosed with DCM in Africa have been shown to be cases of hypertensive heart failure, with varying degrees of myocardial dysfunction. Hypertrophic cardiomyopathy, which in the past was thought to be rare among Africans, has been shown to have the same prevalence as in other parts of the world. Moreover it is now known to be a genetic disorder. Endomyocardial fibrosis has become rare in communities where it used to be common. Its aetiology continues to be elusive. Arrhythmogenic right ventricular cardiomyopathy has been reported among Africans but there are no reports of left ventricular non-compaction or the ion channelopathies from Africa. Lenegre disease and the long-QT syndromes are well-known entities in clinical practice in Africa although long-QT in Africa is associated with potassium deficiency arising from prolonged treatment with diuretics. Left ventricular non-ischaemic aneurysms still occur but are rare. In view of these, a new classification of myocardial disorders was proposed for Africa.
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Affiliation(s)
- A O Falase
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria.
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15
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Bloomfield GS, Barasa FA, Doll JA, Velazquez EJ. Heart failure in sub-Saharan Africa. Curr Cardiol Rev 2013; 9:157-73. [PMID: 23597299 PMCID: PMC3682399 DOI: 10.2174/1573403x11309020008] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 11/15/2012] [Accepted: 11/18/2012] [Indexed: 02/06/2023] Open
Abstract
The heart failure syndrome has been recognized as a significant contributor to cardiovascular disease burden in sub-Saharan African for many decades. Seminal knowledge regarding heart failure in the region came from case reports and case series of the early 20th century which identified infectious, nutritional and idiopathic causes as the most common. With increasing urbanization, changes in lifestyle habits, and ageing of the population, the spectrum of causes of HF has also expanded resulting in a significant burden of both communicable and non-communicable etiologies. Heart failure in sub-Saharan Africa is notable for the range of etiologies that concurrently exist as well as the healthcare environment marked by limited resources, weak national healthcare systems and a paucity of national level data on disease trends. With the recent publication of the first and largest multinational prospective registry of acute heart failure in sub-Saharan Africa, it is timely to review the state of knowledge to date and describe the myriad forms of heart failure in the region. This review discusses several forms of heart failure that are common in sub-Saharan Africa (e.g., rheumatic heart disease, hypertensive heart disease, pericardial disease, various dilated cardiomyopathies, HIV cardiomyopathy, hypertrophic cardiomyopathy, endomyocardial fibrosis, ischemic heart disease, cor pulmonale) and presents each form with regard to epidemiology, natural history, clinical characteristics, diagnostic considerations and therapies. Areas and approaches to fill the remaining gaps in knowledge are also offered herein highlighting the need for research that is driven by regional disease burden and needs.
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Pérez-Mazliah D, Albareda MC, Alvarez MG, Lococo B, Bertocchi GL, Petti M, Viotti RJ, Laucella SA. Allopurinol reduces antigen-specific and polyclonal activation of human T cells. Front Immunol 2012; 3:295. [PMID: 23049532 PMCID: PMC3448060 DOI: 10.3389/fimmu.2012.00295] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Accepted: 09/04/2012] [Indexed: 11/13/2022] Open
Abstract
Allopurinol is the most popular commercially available xanthine oxidase inhibitor and it is widely used for treatment of symptomatic hyperuricaemia, or gout. Although, several anti-inflammatory actions of allopurinol have been demonstrated in vivo and in vitro, there have been few studies on the action of allopurinol on T cells. In the current study, we have assessed the effect of allopurinol on antigen-specific and mitogen-driven activation and cytokine production in human T cells. Allopurinol markedly decreased the frequency of IFN-γ and IL-2-producing T cells, either after polyclonal or antigen-specific stimulation with Herpes Simplex virus 1, Influenza (Flu) virus, tetanus toxoid and Trypanosoma cruzi-derived antigens. Allopurinol attenuated CD69 upregulation after CD3 and CD28 engagement and significantly reduced the levels of spontaneous and mitogen-induced intracellular reactive oxygen species in T cells. The diminished T cell activation and cytokine production in the presence of allopurinol support a direct action of allopurinol on human T cells, offering a potential pharmacological tool for the management of cell-mediated inflammatory diseases.
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Affiliation(s)
- Damián Pérez-Mazliah
- Instituto Nacional de Parasitología "Dr. Mario Fatala Chaben" Ciudad Autónoma de Buenos Aires, Argentina
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Bedi MS, Alvarez RJ, Kubota T, Sheppard R, Kormos RL, Siegenthaler MP, Feldman AM, McTiernan CF, McNamara DM. Myocardial Fas and cytokine expression in end-stage heart failure: impact of LVAD support. Clin Transl Sci 2010; 1:245-8. [PMID: 20443855 DOI: 10.1111/j.1752-8062.2008.00056.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Left ventricular assist device (LVAD) support may facilitate myocardial recovery. We evaluated the impact of LVAD support on Fas expression in a cohort with end-stage heart failure. Myocardial gene expression was assessed pre- and post-LVAD by RNase protection assay and compared to control donor hearts. The expression of Fas is markedly elevated at the time of LVAD support and is tightly correlated with TNF expression. While interleukin (IL)-6 was significantly reduced by LVAD support, the impact of support on Fas was highly variable and tightly linked to tumor necrosis factor (TNF). The role of Fas in predicting recovery after LVAD support requires further investigation.
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Affiliation(s)
- Maninder S Bedi
- Heart Failure/Transplantation Program, Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Shaw SM, Shah MKH, Williams SG, Fildes JE. Immunological mechanisms of pentoxifylline in chronic heart failure. Eur J Heart Fail 2009; 11:113-8. [PMID: 19168508 DOI: 10.1093/eurjhf/hfn040] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The progressive syndrome of chronic heart failure (CHF) represents a common disease pathway that may be derived from a host of varying insults (including myocardial ischaemia and infarction, hypertension, viral infection, pregnancy, etc). Despite this multifarious aetiology, a common phenomena observed in CHF patients is elevated levels of tumour necrosis factor (TNF)-alpha. This has led to the widespread concept that TNF-alpha is directly involved in the pathophysiology of CHF and as such, attempts have been made to inhibit TNF-alpha production in this cohort. However, to date, there have been no clear beneficial effects from TNF-alpha inhibition and indeed trials of direct anti-TNF therapy have provoked worsening of clinical outcomes. Conversely, a possible exception is pentoxifylline (PTX), a putative TNF-alpha inhibitor with possible (but ill-defined) vasodilatory properties. Several small clinical trials assessing the use of PTX in CHF have suggested beneficial effects on multiple surrogate clinical markers. Interestingly, these trials failed to show a concordant effect on circulating TNF despite the clinical improvement, suggesting other key beneficial properties of this novel agent. This review article provides an insight into the potential beneficial mode of the action of PTX in CHF and calls for more investigation of this interesting agent.
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Affiliation(s)
- Steven M Shaw
- The Transplant Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester M23 9LT, UK
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19
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The immune system and chronic heart failure: is the heart in control? J Am Coll Cardiol 2009; 53:1013-20. [PMID: 19298913 DOI: 10.1016/j.jacc.2008.11.046] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2008] [Revised: 10/09/2008] [Accepted: 11/02/2008] [Indexed: 11/21/2022]
Abstract
Despite current treatment options, the clinical course of patients with chronic heart failure is notoriously difficult to predict. Among those with similar etiologies, ejection fractions, and patient demographics, our understanding of why such variations in outcomes exist remains limited. Evidence that has been progressively gathered implicates an important role of the immune system in the propagation of heart failure. This has been derived mainly from observations that cytokines are progressively elevated in patients with poor outcomes. However, attempts at introducing various immunomodulatory therapies as a new treatment strategy have been largely unsuccessful to date. This possibly reflects a failure in recognizing the complexity of the immune system's role in chronic heart failure, which has led to an oversimplified approach to treatment. This review critically analyzes the immune treatments attempted to date and hypothesizes what is required to develop a successful future treatment strategy.
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Kalantar-Zadeh K, Anker SD, Horwich TB, Fonarow GC. Nutritional and anti-inflammatory interventions in chronic heart failure. Am J Cardiol 2008; 101:89E-103E. [PMID: 18514634 DOI: 10.1016/j.amjcard.2008.03.007] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Currently, there are 5 million individuals with chronic heart failure (CHF) in the United States who have poor clinical outcomes, including high death rates. Observational studies have indicated a reverse epidemiology of traditional cardiovascular risk factors in CHF; in contrast to trends seen in the general population, obesity and hypercholesterolemia are associated with improved survival. The temporal discordance between the overnutrition (long-term killer) and undernutrition (short-term killer) not only can explain some of the observed paradoxes but also may indicate that malnutrition, inflammation, and oxidative stress may play a role that results in protein-energy wasting contributing to poor survival in CHF. Diminished appetite or anorexia and nutritional deficiencies may be both a cause and a consequence of this so-called malnutrition-inflammation-cachexia (MIC) or wasting syndrome in CHF. Neurohumoral activation, insulin resistance, cytokine activation, and survival selection-resultant genetic polymorphisms also may contribute to the prominent inflammatory and oxidative characteristics of this population. In patients with CHF and wasting, nutritional strategies including amino acid supplementation may represent a promising therapeutic approach, especially if the provision of additional amino acids, protein, and energy includes nutrients with anti-inflammatory and antioxidant properties. Regardless of the etiology of anorexia, appetite-stimulating agents, especially those with anti-inflammatory properties such as megesterol acetate or pentoxyphylline, may be appropriate adjuncts to dietary supplementation. Understanding the factors that modulate MIC and body wasting and their associations with clinical outcomes in CHF may lead to the development of nutritional strategies that alter the pathophysiology of CHF and improve outcomes.
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Wouters KA, Kremer LCM, Miller TL, Herman EH, Lipshultz SE. Protecting against anthracycline-induced myocardial damage: a review of the most promising strategies. Br J Haematol 2006; 131:561-78. [PMID: 16351632 DOI: 10.1111/j.1365-2141.2005.05759.x] [Citation(s) in RCA: 333] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Over the last 40 years, great progress has been made in treating childhood and adult cancers. However, this progress has come at an unforeseen cost, in the form of emerging long-term effects of anthracycline treatment. A major complication of anthracycline therapy is its adverse cardiovascular effects. If these cardiac complications could be reduced or prevented, higher doses of anthracyclines could potentially be used, thereby further increasing cancer cure rates. Moreover, as the incidence of cardiac toxicity resulting in congestive heart failure or even heart transplantation dropped, the quality and extent of life for cancer survivors would improve. We review the proposed mechanisms of action of anthracyclines and the consequences associated with anthracycline treatment in children and adults. We summarise the most promising current strategies to limit or prevent anthracycline-induced cardiotoxicity, as well as possible strategies to prevent existing cardiomyopathy from worsening.
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Affiliation(s)
- Karlijn A Wouters
- Division of Paediatrics, Vrije Universiteit Medical Centre, Amsterdam, the Netherlands
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22
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Abstract
Background—
Cardiomyopathy, an often irreversible form of heart muscle disease that is associated with a dismal outcome, is endemic in Africa. The primary objective of this review was to summarize the current state of knowledge on the epidemiology and etiology of cardiomyopathy in people living in Africa and to identify new avenues for research.
Methods and Results—
We searched MEDLINE (January 1, 1966, through February 12, 2005) and reference lists of articles for relevant references. Unlike other parts of the world in which cardiomyopathy is rare, dilated cardiomyopathy is a major cause of heart failure throughout Africa. Similarly, peripartum cardiomyopathy is ubiquitous on the continent, with an incidence ranging from 1 in 100 to 1 in 1000 deliveries. There is an apparent marked regional variation in the pathogenesis of dilated cardiomyopathy and peripartum cardiomyopathy, underlining the heterogeneity of causative factors in these conditions. By contrast, endomyocardial fibrosis is restricted to the tropical regions of East, Central, and West Africa. Although the pathogenesis of endomyocardial fibrosis is not fully understood, it seems that the conditioning factors are geography and diet, the triggering factor may be an as yet unidentified infective agent, and the perpetuating factor is eosinophilia. Although epidemiological studies are lacking, hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy seem to have characteristics similar to those of other populations elsewhere in the world.
Conclusions—
There is a need for large-scale epidemiological studies of the incidence, prevalence, determinants, and outcome of cardiomyopathy in Africa to inform strategies for the treatment and prevention of heart muscle disease on the continent.
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Affiliation(s)
- Karen Sliwa
- Department of Cardiology, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
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Sliwa K, Woodiwiss A, Libhaber E, Zhanje F, Libhaber C, Motara R, Essop R. C-reactive protein predicts response to pentoxifylline in patients with idiopathic dilated cardiomyopathy. Eur J Heart Fail 2005; 6:731-4. [PMID: 15542408 DOI: 10.1016/j.ejheart.2003.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2003] [Revised: 09/30/2003] [Accepted: 11/19/2003] [Indexed: 11/22/2022] Open
Affiliation(s)
- Karen Sliwa
- Department of Cardiology, Chris-Hani Baragwanath Hospital, University of the Witwatersrand, P.O. Bertsham, 2013, Johannesburg, South Africa.
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Bahrmann P, Hengst UM, Richartz BM, Figulla HR. Pentoxifylline in ischemic, hypertensive and idiopathic-dilated cardiomyopathy: effects on left-ventricular function, inflammatory cytokines and symptoms. Eur J Heart Fail 2004; 6:195-201. [PMID: 14984727 DOI: 10.1016/j.ejheart.2003.09.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2002] [Revised: 05/16/2003] [Accepted: 09/15/2003] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Tumor necrosis factor (TNF)-alpha and interleukin-6 (IL-6) are significantly elevated in patients with congestive heart failure (CHF). Pentoxifylline, a xanthin-derived agent, is known to inhibit the production of TNF-alpha and IL-6. Recent studies have shown that pentoxifylline produces an increase in ejection fraction, a decrease in left-ventricular chamber size and an improvement in clinical status in patients with idiopathic-dilated cardiomyopathy. Therefore, we studied the effects of pentoxifylline in ischemic, hypertensive and idiopathic-dilated cardiomyopathy. METHODS Primary endpoint was left-ventricular ejection fraction (LVEF) assessed by contrast 2D echocardiography. Secondary endpoints were concentrations of TNF-alpha, IL-6, brain natriuretic peptide, maximal oxygen uptake (VO(2 max)) assessed by cardiopulmonary exercise testing and Minnesota Living with Heart Failure Questionnaire score or New York Heart Association scale. RESULTS Forty-seven patients (31.9% ischemic, 21.3% hypertensive, 10.6% ischemic and hypertensive, 36.2% idiopathic-dilated cardiomyopathy) were randomly assigned to pentoxifylline 600 mg BID (n=23) or placebo (n=24) if they had a compensated CHF with a LVEF less than or equal to 40% and had taken their standard treatment consisting of angiotensin-converting enzyme inhibitors, diuretics and beta-blockers for at least 3 months. Baseline demographic and clinical characteristics of each group were similar. Forty-one patients completed the study protocol and were analysed for primary and secondary endpoints. After 6 months of treatment, LVEF was unchanged in the pentoxifylline group compared with placebo (29+/-7 to 33+/-10% vs. 27+/-9 to 34+/-9%, respectively, P=NS). Also the secondary endpoints did not significantly change during follow-up. CONCLUSION Additional treatment with pentoxifylline is neutral with regard to left-ventricular function, inflammatory cytokines and symptoms in patients with ischemic, hypertensive and idiopathic-dilated cardiomyopathy.
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Affiliation(s)
- Philipp Bahrmann
- Clinic of Internal Medicine I, Friedrich-Schiller-University, Erlanger Allee 101, 07740 Jena, Germany.
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San Martín MA, García A, Rodríguez FJ, Terol I. [Dilated cardiomyopathy and autoimmunity: an overview of current knowledge and perspectives]. Rev Esp Cardiol 2002; 55:514-24. [PMID: 12015932 DOI: 10.1016/s0300-8932(02)76644-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The diagnosis of idiopathic dilated cardiomyopathy is assigned to patients with left ventricular systolic dysfunction and dilatation in the absence of any other documented cause. Idiopathic dilated cardiomyopathy is presumed to have a multifactorial origin, possibly including autoimmune mechanisms. We reviewed the current state of knowledge of this topic, including a pathophysiological hypothesis postulating a relation between an autoimmune process and sympathetic over-stimulation and systolic dysfunction. The implications for therapy are considered in the light of experience with other autoimmune diseases. The results of immunosuppressant treatment and preliminary experiences with immunoadsorption are reviewed and their future perspectives are discussed.
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Affiliation(s)
- Miguel A San Martín
- Servicio de Cardiología, Hospital Carlos III. Instituto de Salud Carlos III, Madrid, Spain
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Skudicky D, Bergemann A, Sliwa K, Candy G, Sareli P. Beneficial effects of pentoxifylline in patients with idiopathic dilated cardiomyopathy treated with angiotensin-converting enzyme inhibitors and carvedilol: results of a randomized study. Circulation 2001; 103:1083-8. [PMID: 11222470 DOI: 10.1161/01.cir.103.8.1083] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We previously reported beneficial effects of pentoxifylline, a xanthine-derived agent known to inhibit the production of tumor necrosis factor-alpha, in patients with idiopathic dilated cardiomyopathy treated with diuretics, digoxin, and ACE inhibitors. Since then, 3 large clinical trials showed important clinical benefits of beta-blockers in this population. Therefore, we designed the present study to establish whether in patients with heart failure already receiving treatment with ACE inhibitors and beta-blockers, the addition of pentoxifylline would have an additive beneficial effect. METHODS AND RESULTS In a single-center, prospective, double-blind, randomized, placebo-controlled study, 39 patients with idiopathic dilated cardiomyopathy were randomized to pentoxifylline 400 mg TID (n=20) or placebo (n=19) if they had a left ventricular ejection fraction <40% after 3 months of therapy with digoxin, ACE inhibitors, and carvedilol. Primary end points were New York Heart Association functional class, exercise tolerance, and left ventricular function. Patients were followed up for 6 months. Five patients died (3 in the placebo group). Patients treated with pentoxifylline had a significant improvement in functional class compared with the placebo group (P:=0.01), with an increment in exercise time from 9.5+/-5 to 12.3+/-6 minutes (P:=0.1). Left ventricular ejection fraction improved from 24+/-9% to 31+/-13%, P:=0.03, in the treatment group. CONCLUSIONS In patients with idiopathic dilated cardiomyopathy, the addition of pentoxifylline to treatment with digoxin, ACE inhibitors, and carvedilol is associated with a significant improvement in symptoms and left ventricular function.
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Affiliation(s)
- D Skudicky
- Department of Cardiology, Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa.
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