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Dungen HD, Petroni R, Correale M, Coiro S, Monitillo F, Triggiani M, Leone M, Antohi EL, Ishihara S, Sarwar CMS, Sabbah HN, Memo M, Metra M, Butler J, Nodari S, Gheorghiade M. A new educational program in heart failure drug development: the Brescia international master program. J Cardiovasc Med (Hagerstown) 2019; 19:411-421. [PMID: 29952846 DOI: 10.2459/jcm.0000000000000669] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
: Despite recent advances in chronic heart failure treatment, prognosis of acute heart failure patients remains poor with a heart failure rehospitalization rate or death reaching approximately 25% during the first 6 months after discharge. In addition, about half of these patients have preserved ejection fraction for which there are no evidence-based therapies. Disappointing results from heart failure clinical trials over the past 20 years emphasize the need for developing novel approaches and pathways for testing new heart failure drugs and devices. Indeed, many trials are being conducted without matching the mechanism and action of the drug with the clinical event. The implementation of these novel approaches should be coupled with the training of a new generation of heart failure physicians and scientists in the art and science of clinical trials. Currently, drug development is led by opinion leaders and experts who, despite their huge personal experience, were never trained systematically on drug development. The aim of this article is to propose a training program of 'drug development in Heart Failure'. A physician attending this course would have to be trained with a major emphasis on heart failure pathophysiology to better match mechanisms of death and rehospitalization with mechanism of action of the drug. Applicants will have to prove their qualifications and special interest in heart failure drug development before enrollment. This article should serve as a roadmap on how to apply emerging general principles in an innovative drug-development-in-heart-failure-process as well as the introduction of a new educational and mentorship program focusing on younger generations of researchers.
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Affiliation(s)
- Hans-Dirk Dungen
- Department of Internal Medicine-Cardiology, Charité Universitäts Medizin, Berlin, Germany
| | - Renata Petroni
- Department of Cardiology, University of L'Aquila, L'Aquila
| | - Michele Correale
- Cardiology Department, Azienda Ospedaliero-Universitaria, Foggia
| | - Stefano Coiro
- Cardiologia e Fisiopatologia Cardiovascolare, University of Perugia, Perugia
| | - Francesco Monitillo
- Cardiovascular Diseases Section, Department of Emergency and Organ Transplantation (DETO), University of Bari, Bari
| | - Marco Triggiani
- Cardiology Section, Department of Clinical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marta Leone
- Cardiovascular Diseases Section, Department of Emergency and Organ Transplantation (DETO), University of Bari, Bari
| | - Elena-Laura Antohi
- ICCU and Cardiology 1st Department, Institute of Emergency for Cardiovascular Diseases 'C.C.Iliescu', Bucharest, Romania
| | - Shiro Ishihara
- Internal Medicine, Cardiology, and Intensive Care Unit, Nippon Medical School Musashi-Kosugi Hospital, Kawasaky, Japan
| | | | - Hani N Sabbah
- Division of Cardiovascular Medicine, Department of Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Maurizio Memo
- Section of Pharmacology, Department of Molecular and Translational Medicine
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Javed Butler
- Cardiology Division, Stony Brook University, New York, New York
| | - Savina Nodari
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Pharmacological reasons that may explain why randomized clinical trials have failed in acute heart failure syndromes. Int J Cardiol 2016; 233:1-11. [PMID: 28161130 DOI: 10.1016/j.ijcard.2016.11.124] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/04/2016] [Accepted: 11/06/2016] [Indexed: 12/27/2022]
Abstract
Acute heart failure (AHF) represents a clinical challenge as it encloses a heterogeneous group of syndromes (AHFS) with different pathophysiology, clinical presentations, prognosis and response to therapy. In the last 25years multiple therapeutic targets have been identified and numerous new drugs were evaluated but, up to now, all failed to demonstrate a consistent benefit on clinical outcomes. Moreover, a repeated finding has been the poor correlation between the encouraging results of preclinical and early clinical trials and the lack of effect on outcomes observed in phase III trials. We review several possible pharmacological reasons that may explain the lack of success to develop new drugs and the pharmacological challenges to overcome in the future to develop new more effective and safer drugs for the treatment of AHFS.
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Sarwar M, Du XJ, Dschietzig TB, Summers RJ. The actions of relaxin on the human cardiovascular system. Br J Pharmacol 2016; 174:933-949. [PMID: 27239943 DOI: 10.1111/bph.13523] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/01/2016] [Accepted: 04/26/2016] [Indexed: 12/14/2022] Open
Abstract
The insulin-like peptide relaxin, originally identified as a hormone of pregnancy, is now known to exert a range of pleiotropic effects including vasodilatory, anti-fibrotic, angiogenic, anti-apoptotic and anti-inflammatory effects in both males and females. Relaxin produces these effects by binding to a cognate receptor RXFP1 and activating a variety of signalling pathways including cAMP, cGMP and MAPKs as well as by altering gene expression of TGF-β, MMPs, angiogenic growth factors and endothelin receptors. The peptide has been shown to be effective in halting or reversing many of the adverse effects including fibrosis in animal models of cardiovascular disease including ischaemia/reperfusion injury, myocardial infarction, hypertensive heart disease and cardiomyopathy. Relaxin given to humans is safe and produces favourable haemodynamic changes. Serelaxin, the recombinant form of relaxin, is now in extended phase III clinical trials for the treatment of acute heart failure. Previous clinical studies indicated that a 48 h infusion of relaxin improved 180 day mortality, yet the mechanism underlying this effect is not clear. This article provides an overview of the cellular mechanism of effects of relaxin and summarizes its beneficial actions in animal models and in the clinic. We also hypothesize potential mechanisms for the clinical efficacy of relaxin, identify current knowledge gaps and suggest new ways in which relaxin could be useful therapeutically. LINKED ARTICLES This article is part of a themed section on Recent Progress in the Understanding of Relaxin Family Peptides and their Receptors. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.10/issuetoc.
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Affiliation(s)
- Mohsin Sarwar
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Australia
| | - Xiao-Jun Du
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Thomas B Dschietzig
- Immundiagnostik AG, Bensheim, Germany.,Campus Mitte, Medical Clinic for Cardiology and Angiology, Charité-University Medicine Berlin, Berlin, Germany.,Relaxera Pharmazeutische Gesellschaft mbH & Co. KG, Bensheim, Germany
| | - Roger J Summers
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Australia
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Davison BA, Metra M, Cotter G, Massie BM, Cleland JGF, Dittrich HC, Edwards C, Filippatos G, Givertz MM, Greenberg B, Ponikowski P, Voors AA, O'Connor CM, Teerlink JR. Worsening Heart Failure Following Admission for Acute Heart Failure: A Pooled Analysis of the PROTECT and RELAX-AHF Studies. JACC-HEART FAILURE 2016; 3:395-403. [PMID: 25951761 DOI: 10.1016/j.jchf.2015.01.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 01/06/2015] [Accepted: 01/07/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVES These studies conducted analyses to examine patient characteristics and outcomes associated with worsening heart failure (WHF). BACKGROUND WHF during an admission for acute heart failure (AHF) represents treatment failure and is a potential therapeutic target for clinical trials of AHF. METHODS Individual patient data from the PROTECT (Placebo-Controlled Randomized Study of the Selective A1 Adenosine Receptor Antagonist Rolofylline for Patients Hospitalized with Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function) and RELAX-AHF (Relaxin in Acute Heart Failure) phase II and III studies were pooled for analysis. RESULTS Of 3,691 patients, death or WHF through day 5 occurred in 12.4%, ranging from 9.5% to 14.5% among studies. A multivariable model provided modest discrimination between patients who did or did not develop WHF (C-index = 0.68). After multivariable adjustment, WHF was associated with a mean increase in length of stay of 5.2 days (95% confidence interval [CI]: 4.6 to 5.8 days) and increased risks of 60-day HF or renal failure readmission or cardiovascular death (hazard ratio [HR]: 1.64, 95% CI: 1.34 to 2.01) and 180-day mortality (HR: 1.93, 95% CI: 1.55 to 2.41) (all p < 0.001). The risk of mortality was higher in patients whose WHF required intravenous inotropes or mechanical therapy (HR: 3.03, 95% CI: 2.11 to 4.36) compared with patients whose WHF was treated with intravenous loop diuretic alone (HR: 1.80, 95% CI: 1.36 to 2.36) (both p < 0.001). WHF was associated with larger increases in markers of renal and hepatic dysfunction during the first days of admission, but remained significantly associated with adverse outcomes after adjustment for these changes. CONCLUSIONS WHF during the first 5 days of admission for AHF occurred in approximately 10% to 15% of patients and was associated with longer length of stay and higher risk for readmission and death.
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Affiliation(s)
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Gad Cotter
- Momentum Research Inc., Durham, North Carolina
| | - Barry M Massie
- Division of Cardiology, School of Medicine, University of California-San Francisco, San Francisco, California
| | - John G F Cleland
- Department of Cardiology, University of Hull, Kingston upon Hull, United Kingdom; National Heart and Lung Institute, Royal Brompton and Harefield Hospitals National Health Service Trust, Imperial College, London, United Kingdom
| | | | | | | | - Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Barry Greenberg
- Division of Cardiology, University of California at San Diego, San Diego, California
| | - Piotr Ponikowski
- Department of Cardiology, Medical University, Clinical Military Hospital, Wroclaw, Poland
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, Groningen, the Netherlands
| | | | - John R Teerlink
- Division of Cardiology, School of Medicine, University of California-San Francisco, San Francisco, California; Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, California
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Martín-Sánchez FJ, Rodríguez-Adrada E, Llorens P, Formiga F. [Key messages for the initial management of the elderly patient with acute heart failure]. Rev Esp Geriatr Gerontol 2015; 50:185-194. [PMID: 25959134 DOI: 10.1016/j.regg.2015.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/08/2015] [Accepted: 02/09/2015] [Indexed: 06/04/2023]
Abstract
Acute heart failure is a high prevalence geriatric syndrome that has become one of the most frequent causes of visits to emergency departments, as well as hospital admission, and is associated with high morbidity, mortality and functional impairment. There has been an increasing amount of information published in recent years on the initial management of acute heart failure and the results of the short-term outcomes, as well as the natural history of the disease. The objective of this study is to provide several recommendations that should be taken into account in the initial management of the elderly patient with acute heart failure in the emergency departments, and to review the most interesting currently on-going clinical trials.
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Affiliation(s)
- F Javier Martín-Sánchez
- Servicio de Urgencias, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España.
| | - Esther Rodríguez-Adrada
- Servicio de Urgencias, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - Pere Llorens
- Servicio de Urgencias, Hospital General Universitario de Alicante, Alicante, España
| | - Francesc Formiga
- Programa Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España
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Affiliation(s)
- Beth Davison
- Momentum Research Inc; 3100 Tower Blvd, Suite 802 Durham NC 27707 USA
| | - Gad Cotter
- Momentum Research Inc; 3100 Tower Blvd, Suite 802 Durham NC 27707 USA
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Relaxin for Treatment of Acute Heart Failure: Making the Case for Treating Targeted Patient Profiles. Curr Heart Fail Rep 2013; 10:198-203. [DOI: 10.1007/s11897-013-0148-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Inhibition of CatA: an emerging strategy for the treatment of heart failure. Future Med Chem 2013; 5:399-409. [DOI: 10.4155/fmc.13.24] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The lysosomal serine carboxypeptidase CatA has a very important and well-known structural function as well as a, so far, less explored catalytic function. A complete loss of the CatA protein results in the lysosomal storage disease galactosialidosis caused by intralysosomal degradation of β-galactosidase and neuraminidase 1. However, mice with a catalytically inactive CatA enzyme show no signs of this disease. This observation establishes a clear distinction between structural and catalytic functions of the CatA enzyme. Recently, several classes of orally bioavailable synthetic inhibitors of CatA have been identified. Pharmacological studies in rodents indicate a remarkable influence of CatA inhibition on cardiovascular disease progression and identify CatA as a promising novel target for the treatment of heart failure.
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Sun H, Davison BA, Cotter G, Pencina MJ, Koch GG. Evaluating Treatment Efficacy by Multiple End Points in Phase II Acute Heart Failure Clinical Trials. Circ Heart Fail 2012; 5:742-9. [DOI: 10.1161/circheartfailure.112.969154] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
To assess concomitant simultaneous effects on multiple end points using global statistical methods in phase II acute heart failure studies.
Methods and Results—
Using simulations we have assessed different statistical methods to evaluate concomitant effects of a new intervention on dyspnea relief (using 2 measures), length of hospital stay, worsening heart failure to 5 days, mortality, and heart failure readmission to 30 days. Treatment effect scenarios included large (20% to 28% relative improvements) and very large (30% to 43% relative improvements) effects among others. Placebo responses and correlations among end points typical in recent acute heart failure clinical trials were used. Powers for the average Z score exceeded 70% with ≥75 patients per group for 35% relative improvement across all 6 end points. Assessing dyspnea alone generally provides lower power than the average Z score approach, with power deducted ≈50% under most of scenarios. Other approaches generally provide lower power than the average Z score method.
Conclusions—
Assessing the effects of new therapies on multiple clinical end points using the average Z score enables detection of therapeutic efficacy using sample sizes of 100 to 150 patients per group, approximately double the power achievable assessing the effects on dyspnea alone.
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Affiliation(s)
- Hengrui Sun
- From the Momentum Research Inc., Durham, NC (H.S., B.A.D., G.C.); Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC (H.S., G.G.K.); and Harvard Clinical Research Institute, Boston, MA (M.J.P.)
| | - Beth A. Davison
- From the Momentum Research Inc., Durham, NC (H.S., B.A.D., G.C.); Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC (H.S., G.G.K.); and Harvard Clinical Research Institute, Boston, MA (M.J.P.)
| | - Gad Cotter
- From the Momentum Research Inc., Durham, NC (H.S., B.A.D., G.C.); Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC (H.S., G.G.K.); and Harvard Clinical Research Institute, Boston, MA (M.J.P.)
| | - Michael J. Pencina
- From the Momentum Research Inc., Durham, NC (H.S., B.A.D., G.C.); Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC (H.S., G.G.K.); and Harvard Clinical Research Institute, Boston, MA (M.J.P.)
| | - Gary G. Koch
- From the Momentum Research Inc., Durham, NC (H.S., B.A.D., G.C.); Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC (H.S., G.G.K.); and Harvard Clinical Research Institute, Boston, MA (M.J.P.)
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Abstract
BACKGROUND Acute heart failure (AHF) remains a major public health burden with a high prevalence and poor prognosis. Relaxin is a naturally occurring peptide hormone that increases cardiac output, arterial compliance, and renal blood flow during pregnancy. The RELAX-AHF-1 study will evaluate the effect of RLX030 (recombinant form of human relaxin 2) on symptom relief and clinical outcomes in patients with AHF. METHODS The protocol includes a completed phase 2 234-patient dose-finding study (Pre-RELAX-AHF) and an ongoing phase 3 1,160-patient trial (RELAX-AHF-1). Patients with AHF and systolic blood pressure >125 mm Hg are randomized within 16 hours of presentation to a 48-hour IV infusion of RLX030 or placebo. The 30 μg/kg per day dose of RLX030 was chosen for RELAX-AHF-1 based on effects on dyspnea, clinical outcomes, and safety observed in Pre-RELAX-AHF. Primary efficacy end points in RELAX-AHF-1 are (1) the area under the curve of change of the dyspnea Visual Analog Scale from baseline through day 5 and (2) whether the patient reports moderately to markedly better dyspnea at 6, 12, and 24 hours. Secondary efficacy end points include days alive and out of the hospital through day 60 and cardiovascular death or rehospitalization for heart failure or renal failure through day 60. Patients will be followed up through day 180 for mortality. As of September 19, 2011, 978 patients have been enrolled. CONCLUSIONS Pre-RELAX-AHF results suggested that infusion of RLX030 may accelerate dyspnea relief and improve prognosis in patients hospitalized with AHF. RELAX-AHF-1 will further evaluate these effects.
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Davison BA, Cotter G, Sun H, Chen L, Teerlink JR, Metra M, Felker GM, Voors AA, Ponikowski P, Filippatos G, Greenberg B, Teichman SL, Unemori E, Koch GG. Permutation criteria to evaluate multiple clinical endpoints in a proof-of-concept study: lessons from Pre-RELAX-AHF. Clin Res Cardiol 2011; 100:745-53. [PMID: 21416190 PMCID: PMC3167045 DOI: 10.1007/s00392-011-0304-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 02/21/2011] [Indexed: 12/05/2022]
Abstract
Background Clinically relevant endpoints cannot be routinely targeted with reasonable power in a small study. Hence, proof-of-concept studies are often powered to a primary surrogate endpoint. However, in acute heart failure (AHF) effects on surrogates have not translated into clinical benefit in confirmatory studies. Although observing an effect on one of many endpoints due to chance is likely, observing concurrent positive trends across several outcomes by chance is usually unlikely. Methods Pre-RELAX-AHF, which compared 4 relaxin doses with placebo in AHF, has shown favourable trends versus placebo (one-sided P < 0.10) on six of nine clinical endpoints in the 30 μg/kg/day group. To illustrate evaluation of multiple, correlated clinical endpoints for evidence of efficacy and for dose selection, a permutation method was applied retrospectively. By randomly re-assigning the treatment group to the actual data for each of the 229 subjects, 20,000 permutation samples were constructed. Results The permutation P value for at least six favourable trends among nine endpoints in any dose groups was 0.0073 (99.9% CI 0.0053–0.0093). This is higher than would be expected if the endpoints were uncorrelated (0.00026), but much lower than the probability of observing one of nine comparisons significant at the traditional two-sided P < 0.05 (0.74). Thus, the result was unlikely due to correlated endpoints or to chance. Conclusions Examining consistency of effect across multiple clinical endpoints in a proof-of-concept study may identify efficacious therapies and enable dose selection for confirmatory trials. The merit of the approach described requires confirmation through prospective application in designing future studies.
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