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Wang X, Zhao X, Wang X, Cao L, Lu B, Wang Z, Zhang W, Ti Y, Zhong M. Effect of levosimendan on ventricular remodelling in patients with left ventricular systolic dysfunction: a meta-analysis. ESC Heart Fail 2024; 11:1352-1376. [PMID: 38419326 PMCID: PMC11098670 DOI: 10.1002/ehf2.14714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 03/02/2024] Open
Abstract
Heart failure is the final stage of several cardiovascular diseases, and the key to effectively treating heart failure is to reverse or delay ventricular remodelling. Levosimendan is a novel inotropic and vasodilator agent used in heart failure, whereas the impact of levosimendan on ventricular remodelling is still unclear. This study aims to investigate the impact of levosimendan on ventricular remodelling in patients with left ventricular systolic dysfunction. Electronic databases were searched to identify eligible studies. A total of 66 randomized controlled trials involving 7968 patients were included. Meta-analysis results showed that levosimendan increased left ventricular ejection fraction [mean difference (MD) = 3.62, 95% confidence interval (CI) (2.88, 4.35), P < 0.00001] and stroke volume [MD = 6.59, 95% CI (3.22, 9.96), P = 0.0001] and significantly reduced left ventricular end-systolic volume [standard mean difference (SMD) = -0.52, 95% CI (-0.67, -0.37), P < 0.00001], left ventricular end-diastolic volume index [SMD = -1.24, 95% CI (-1.61, -0.86), P < 0.00001], and left ventricular end-systolic volume index [SMD = -1.06, 95% CI (-1.43, -0.70), P < 0.00001]. In terms of biomarkers, levosimendan significantly reduced the level of brain natriuretic peptide [SMD = -1.08, 95% CI (-1.60, -0.56), P < 0.0001], N-terminal pro-brain natriuretic peptide [SMD = -0.99, 95% CI (-1.41, -0.56), P < 0.00001], and interleukin-6 [SMD = -0.61, 95% CI (-0.86, -0.35), P < 0.00001]. Meanwhile, levosimendan may increase the incidence of hypotension [risk ratio (RR) = 1.24, 95% CI (1.12, 1.39), P < 0.0001], hypokalaemia [RR = 1.57, 95% CI (1.08, 2.28), P = 0.02], headache [RR = 1.89, 95% CI (1.50, 2.39), P < 0.00001], atrial fibrillation [RR = 1.31, 95% CI (1.12, 1.52), P = 0.0005], and premature ventricular complexes [RR = 1.86, 95% CI (1.27, 2.72), P = 0.001]. In addition, levosimendan reduced all-cause mortality [RR = 0.83, 95% CI (0.74, 0.94), P = 0.002]. In conclusion, our study found that levosimendan might reverse ventricular remodelling when applied in patients with left ventricular systolic dysfunction, especially in patients undergoing cardiac surgery, decompensated heart failure, and septic shock.
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Affiliation(s)
- Xia Wang
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Xiu‐Zhi Zhao
- Department of CardiologyPeople's Hospital of Lixia District of JinanJinanShandongChina
| | - Xi‐Wen Wang
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Lu‐Ying Cao
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Bin Lu
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Zhi‐Hao Wang
- Department of Geriatric MedicineShandong Key Laboratory of Cardiovascular Proteomics, Qilu Hospital, Cheeloo College of Medicine, Shandong UniversityJinanChina
| | - Wei Zhang
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Yun Ti
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Ming Zhong
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
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2
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H Brandt-Jacobsen N, Johansen ML, Rasmussen JJ, Dalsgaard M, Kumler T, Faber J, Rossignol P, Schou M, Kistorp C. Effect on cardiac function among patients with type 2 diabetes following high-dose mineralocorticoid receptor antagonist using echocardiography; data from the MIRAD randomized clinical trial. BMC Cardiovasc Disord 2023; 23:175. [PMID: 37003987 PMCID: PMC10064675 DOI: 10.1186/s12872-023-03183-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/14/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Early heart failure prevention is central in patients with type 2 diabetes, and mineralocorticoid receptor antagonists (MRAs) have shown to improve prognosis. We investigated the effect of high-dose MRA, eplerenone, on cardiac function and structure in patients with type 2 diabetes and established or increased risk of cardiovascular disease but without heart failure. METHODS In the current randomized, placebo-controlled clinical trial, 140 patients with high-risk type 2 diabetes were randomized to high-dose eplerenone (100-200 mg daily) or placebo as add-on to standard care for 26 weeks. Left ventricular systolic and diastolic function, indexed left ventricular mass (LVMi), and global longitudinal strain (GLS) were assessed using echocardiography at baseline and after 26 weeks of treatment. RESULTS Of the included patients, 138 (99%) had an echocardiography performed at least once. Baseline early diastolic in-flow velocity (E-wave) indexed by mitral annulus velocity (e') was mean (SD) 11.1 (0.5), with 31% of patients reaching above 12. No effect of treatment on diastolic function was observed measured by E/e' (0.0, 95%CI [-1.2 to 1.2], P = 0.992) or E/A (-0.1, 95%CI [-0.2 to 0.0], P = 0.191). Mean left ventricular ejection fraction (LVEF) at baseline was 59.0% (8.0). No improvement in systolic function was observed when comparing groups after 26 weeks (LVEF: 0.9, 95%CI [-1.1 to 2.8], P = 0.382; GLS: -0.4%, 95%CI [-1.5 to 0.6], P = 0.422), nor in LVMi (-3.8 g/m2 95%CI [-10.2 to 2.7], P = 0.246). CONCLUSION In the present echo sub-study, no change in left ventricular function was observed following high-dose MRA therapy in patients with type 2 diabetes when evaluated by conventional echocardiography. TRIAL REGISTRATION Date of registration 25/08/2015 (EudraCT number: 2015-002,519-14).
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Affiliation(s)
- Niels H Brandt-Jacobsen
- Department of Endocrinology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marie Louise Johansen
- Department of Endocrinology-Internal Medicine, Copenhagen University Hospital - Herlev and Gentofte Hospital, Herlev, Denmark
| | - Jon J Rasmussen
- Department of Endocrinology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten Dalsgaard
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Herlev, Denmark
| | - Thomas Kumler
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Herlev, Denmark
| | - Jens Faber
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Endocrinology-Internal Medicine, Copenhagen University Hospital - Herlev and Gentofte Hospital, Herlev, Denmark
| | - Patrick Rossignol
- Université de Lorraine, Nancy, France
- Department de Défaillance Cardiovasculaire Aiguë et Chronique, L'Institut National de la Santé et de la Recherche Médicale (URM-S 116), Nancy, France
- Centre Hospitalier Régional Universitaire, Nancy, France
- French Clinical Research Infrastructure Network Investigation Network Initiative - Cardiovascular and Renal Clinical Trialists, Nancy, France
- Centre d'Investigation Clinique Plurithématique 1433, L'Institut National de la Santé et de la Recherche Médicale, Nancy, France
| | - Morten Schou
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Herlev, Denmark
| | - Caroline Kistorp
- Department of Endocrinology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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3
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Hnat T, Veselka J, Honek J. Left ventricular reverse remodelling and its predictors in non-ischaemic cardiomyopathy. ESC Heart Fail 2022; 9:2070-2083. [PMID: 35437948 PMCID: PMC9288763 DOI: 10.1002/ehf2.13939] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 02/16/2022] [Accepted: 04/04/2022] [Indexed: 11/21/2022] Open
Abstract
Adverse remodelling following an initial insult is the hallmark of heart failure (HF) development and progression. It is manifested as changes in size, shape, and function of the myocardium. While cardiac remodelling may be compensatory in the short term, further neurohumoral activation and haemodynamic overload drive this deleterious process that is associated with impaired prognosis. However, in some patients, the changes may be reversed. Left ventricular reverse remodelling (LVRR) is characterized as a decrease in chamber volume and normalization of shape associated with improvement in both systolic and diastolic function. LVRR might occur spontaneously or more often in response to therapeutic interventions that either remove the initial stressor or alleviate some of the mechanisms that contribute to further deterioration of the failing heart. Although the process of LVRR in patients with new‐onset HF may take up to 2 years after initiating treatment, there is a significant portion of patients who do not improve despite optimal therapy, which has serious clinical implications when considering treatment escalation towards more aggressive options. On the contrary, in patients that achieve delayed improvement in cardiac function and architecture, waiting might avoid untimely implantable cardioverter‐defibrillator implantation. Therefore, prognostication of successful LVRR based on clinical, imaging, and biomarker predictors is of utmost importance. LVRR has a positive impact on prognosis. However, reverse remodelled hearts continue to have abnormal features. In fact, most of the molecular, cellular, interstitial, and genome expression abnormalities remain and a susceptibility to dysfunction redevelopment under biomechanical stress persists in most patients. Hence, a distinction should be made between reverse remodelling and true myocardial recovery. In this comprehensive review, current evidence on LVRR, its predictors, and implications on prognostication, with a specific focus on HF patients with non‐ischaemic cardiomyopathy, as well as on novel drugs, is presented.
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Affiliation(s)
- Tomas Hnat
- Department of Cardiology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, V Úvalu 84/1, Prague, 15006, Czech Republic
| | - Josef Veselka
- Department of Cardiology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, V Úvalu 84/1, Prague, 15006, Czech Republic
| | - Jakub Honek
- Department of Cardiology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, V Úvalu 84/1, Prague, 15006, Czech Republic
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Fu X, Almenglo C, Fernandez ÁL, Martínez-Cereijo JM, Iglesias-Alvarez D, Duran-Muñoz D, García-Caballero T, Gonzalez-Juanatey JR, Rodriguez-Mañero M, Eiras S. The Effect of Mineralocorticoid Receptor 3 Antagonists on Anti-Inflammatory and Anti-Fatty Acid Transport Profile in Patients with Heart Failure. Cells 2022; 11:cells11081264. [PMID: 35455943 PMCID: PMC9027091 DOI: 10.3390/cells11081264] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 02/01/2023] Open
Abstract
Epicardial fat thickness is associated with cardiovascular disease. Mineralocorticoid receptor antagonist (MRA), a pharmaceutical treatment for CVD, was found to have an effect on adipose tissue. Our aim was to analyse the main epicardial fat genesis and inflammation-involved cell markers and their regulation by risk factors and MRA. We included blood and epicardial or subcutaneous fat (EAT or SAT) from 71 patients undergoing heart surgery and blood from 66 patients with heart failure. Cell types (transcripts or proteins) were analysed by real-time polymerase chain reaction or immunohistochemistry. Plasma proteins were analysed by Luminex technology or enzyme-linked immunoassay. Our results showed an upregulation of fatty acid transporter levels after aldosterone-induced genesis. The MRA intake was the main factor associated with lower levels in epicardial fat. On the contrary, MRA upregulated the levels and its secretion of the anti-inflammatory marker intelectin 1 and reduced the proliferation of epicardial fibroblasts. Our results have shown the local MRA intake effect on fatty acid transporters and anti-inflammatory marker levels and the proliferation rate on epicardial fat fibroblasts. They suggest the role of MRA on epicardial fat genesis and remodelling in patients with cardiovascular disease. Translational perspective: the knowledge of epicardial fat genesis and its modulation by drugs might be useful for improving the treatments of cardiovascular disease.
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Affiliation(s)
- Xiaoran Fu
- Translational Cardiology Group, Health Research Institute, 15706 Santiago de Compostela, Spain;
| | - Cristina Almenglo
- Cardiology Group, Health Research Institute, University Hospital of Santiago de Compostela, 15706 Santiago de Compostela, Spain; (C.A.); (D.I.-A.); (J.R.G.-J.)
| | - Ángel Luis Fernandez
- Heart Surgery Department, University Hospital of Santiago de Compostela, 15706 Santiago de Compostela, Spain; (Á.L.F.); (J.M.M.-C.); (D.D.-M.)
- CIBERCV Madrid, Department of Morphological Sciences, University of Santiago de Compostela, 15706 Santiago de Compostela, Spain
| | - José Manuel Martínez-Cereijo
- Heart Surgery Department, University Hospital of Santiago de Compostela, 15706 Santiago de Compostela, Spain; (Á.L.F.); (J.M.M.-C.); (D.D.-M.)
| | - Diego Iglesias-Alvarez
- Cardiology Group, Health Research Institute, University Hospital of Santiago de Compostela, 15706 Santiago de Compostela, Spain; (C.A.); (D.I.-A.); (J.R.G.-J.)
| | - Darío Duran-Muñoz
- Heart Surgery Department, University Hospital of Santiago de Compostela, 15706 Santiago de Compostela, Spain; (Á.L.F.); (J.M.M.-C.); (D.D.-M.)
- CIBERCV Madrid, Department of Morphological Sciences, University of Santiago de Compostela, 15706 Santiago de Compostela, Spain
| | - Tomás García-Caballero
- Morphological Sciences Department, Medicine Faculty, University of Santiago de Compostela and Pathology Department, University Hospital of Santiago de Compostela, 15706 Santiago de Compostela, Spain;
| | - Jose Ramón Gonzalez-Juanatey
- Cardiology Group, Health Research Institute, University Hospital of Santiago de Compostela, 15706 Santiago de Compostela, Spain; (C.A.); (D.I.-A.); (J.R.G.-J.)
- CIBERCV Madrid, Department of Morphological Sciences, University of Santiago de Compostela, 15706 Santiago de Compostela, Spain
- Cardiology Department, University Hospital of Santiago de Compostela, 15706 Santiago de Compostela, Spain
| | - Moises Rodriguez-Mañero
- Translational Cardiology Group, Health Research Institute, 15706 Santiago de Compostela, Spain;
- CIBERCV Madrid, Department of Morphological Sciences, University of Santiago de Compostela, 15706 Santiago de Compostela, Spain
- Cardiology Department, University Hospital of Santiago de Compostela, 15706 Santiago de Compostela, Spain
- Correspondence: (M.R.-M.); (S.E.); Tel.: +34-616903275 (M.R.-M.); +34-981955074 (S.E.)
| | - Sonia Eiras
- Translational Cardiology Group, Health Research Institute, 15706 Santiago de Compostela, Spain;
- CIBERCV Madrid, Department of Morphological Sciences, University of Santiago de Compostela, 15706 Santiago de Compostela, Spain
- Correspondence: (M.R.-M.); (S.E.); Tel.: +34-616903275 (M.R.-M.); +34-981955074 (S.E.)
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5
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Boulmpou A, Theodorakopoulou MP, Alexandrou ME, Boutou AK, Papadopoulos CE, Pella E, Sarafidis P, Vassilikos V. Meta-analysis addressing the impact of cardiovascular-acting medication on peak oxygen uptake of patients with HFpEF. Heart Fail Rev 2022; 27:609-623. [DOI: 10.1007/s10741-021-10207-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/09/2021] [Indexed: 11/28/2022]
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6
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Brandt-Jacobsen NH, Lav Madsen P, Johansen ML, Rasmussen JJ, Forman JL, Holm MR, Rye Jørgensen N, Faber J, Rossignol P, Schou M, Kistorp C. Mineralocorticoid Receptor Antagonist Improves Cardiac Structure in Type 2 Diabetes: Data From the MIRAD Trial. JACC-HEART FAILURE 2021; 9:550-558. [PMID: 34325885 DOI: 10.1016/j.jchf.2021.02.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This study investigated the impact of the MR antagonist (MRA) eplerenone on LVM in type 2 diabetes patients at high risk for cardiovascular disease (CVD). BACKGROUND MRA activation is associated with cardiac fibrosis and increased left ventricular mass (LVM), which is an independent predictor of adverse CVD, including heart failure in patients with type 2 diabetes. METHODS A prespecified analysis of secondary endpoints in a randomized, double-blinded clinical trial of 140 patients with type 2 diabetes at high risk of or established CVD. Patients were randomized to receive high-dose eplerenone therapy (100 mg-200 mg) or placebo as an add-on to standard care for 26 weeks. Indexed LVM (LVMi) and T1 time were measured using cardiac magnetic resonance (CMR) imaging. Biomarkers included N-terminal pro-B-type natriuretic peptide (NT-proBNP), pro-collagen type I N-terminal propeptide (P1NP), and type III N-terminal propeptide (P3NP). RESULTS Of 140 patients in the MIRAD trial, 104 patients were subject to CMR imaging (eplerenone: 54 patients; placebo: 50 patients). Mean LVMi at baseline was 74.2 ± 16 g/m2. The treatment effect (ie, between-group differences) was a decrease of 3.7 g/m2 following the eplerenone treatment (95% CI: -6.7 to -0.7; P = 0.017), with a corresponding decrease in absolute LVM. Plasma NT-proBNP concentrations decreased by 22% (P = 0.017) using eplerenone compared with placebo, and P1NP decreased 3.3 ng/mL (P = 0.019). No differences in T1 times or P3NP concentrations were observed between groups. CONCLUSIONS The addition of high-dose eplerenone in high-risk type 2 diabetes was associated with a clear reduction in LVMi and in NT-proBNP and P1NP levels, which may suggest a clinical benefit in heart failure prevention. (EU Clinical trials: Mineralocorticoid Receptor Antagonists in Type 2 Diabetes [MIRAD]; 2015-002519-14).
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Affiliation(s)
- Niels H Brandt-Jacobsen
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Per Lav Madsen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marie Louise Johansen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Endocrinology-Internal Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jon J Rasmussen
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Julie L Forman
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Maria R Holm
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Niklas Rye Jørgensen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens Faber
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Endocrinology-Internal Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Patrick Rossignol
- Université de Lorraine, Nancy, France; Departement de défaillance cardiovasculaire aiguë et chronique de l'institut national de la santé et de la recherche médicale (UMR-S 1116), Nancy, France; Centre Hospitalier Régional Universitaire, Nancy, France; Centre d'Investigation Clinique Plurithémathique 1433 de l' institut national de la santé et de la recherche médicale, Nancy, France; French Clinical Research Infrastructure Network Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Morten Schou
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Caroline Kistorp
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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7
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Demkes EJ, Wenker S, Silvis MJM, van Nieuwburg MMJ, Visser MJ, Jansen MS, Brans MAD, Velema E, Sluijter JPG, Hoefer IE, de Kleijn DPV, Timmers L, de Jager SCA. Neutral Effects of Combined Treatment With GLP-1R Agonist Exenatide and MR Antagonist Potassium Canrenoate on Cardiac Function in Porcine and Murine Chronic Heart Failure Models. Front Pharmacol 2021; 12:702326. [PMID: 34381364 PMCID: PMC8352472 DOI: 10.3389/fphar.2021.702326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/12/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Ischemia-reperfusion and cardiac remodeling is associated with cardiomyocyte death, excessive fibrosis formation, and functional decline, eventually resulting in heart failure (HF). Glucagon-like peptide (GLP)-1 agonists are reported to reduce apoptosis and myocardial infarct size after ischemia-reperfusion. Moreover, mineralocorticoid receptor antagonists (MRAs) have been described to reduce reactive fibrosis and improve cardiac function. Here, we investigated whether combined treatment with GLP-1R agonist exenatide and MRA potassium canrenoate could minimize cardiac injury and limit HF progression in animal models of chronic HF. Methods and Results: Forty female Topigs Norsvin pigs were subjected to 150 min balloon occlusion of the left anterior descending artery (LAD). Prior to reperfusion, pigs were randomly assigned to placebo or combination therapy (either low dose or high dose). Treatment was applied for two consecutive days or for 8 weeks with a continued high dose via a tunneled intravenous catheter. Using 2,3,5-Triphenyltetrazolium chloride (TTC) staining we observed that combination therapy did not affect the scar size after 8 weeks. In line, left ventricular volume and function assessed by three-dimensional (3D) echocardiography (baseline, 7 days and 8 weeks), and cardiac magnetic resonance imaging (CMR, 8 weeks) did not differ between experimental groups. In addition, 36 C57Bl/6JRj mice underwent permanent LAD-occlusion and were treated with either placebo or combination therapy prior to reperfusion, for two consecutive days via intravenous injection, followed by continued treatment via placement of osmotic mini-pumps for 28 days. Global cardiac function, assessed by 3D echocardiography performed at baseline, 7, 14, and 28 days, did not differ between treatment groups. Also, no differences were observed in cardiac hypertrophy, assessed by heart weight/bodyweight and heart weight/tibia length ratio. Conclusion: In the current study, combined treatment with GLP-1R agonist exenatide and MR antagonist potassium canrenoate did not show beneficial effects on cardiac remodeling nor resulted in functional improvement in a small and large animal chronic HF model.
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Affiliation(s)
- Evelyne J Demkes
- Department of Cardiology, Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht, Netherlands.,UMC Utrecht Regenerative Medicine Center, Circulatory Health Laboratory, University Utrecht, University Medical Center Utrecht, Utrecht, Netherlands
| | - Steven Wenker
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Max J M Silvis
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Martijn M J van Nieuwburg
- Department of Cardiology, Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - M Joyce Visser
- Department of Cardiology, Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marlijn S Jansen
- Department of Cardiology, Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Maike A D Brans
- Department of Cardiology, Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Evelyn Velema
- Department of Cardiology, Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Joost P G Sluijter
- Department of Cardiology, Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht, Netherlands.,UMC Utrecht Regenerative Medicine Center, Circulatory Health Laboratory, University Utrecht, University Medical Center Utrecht, Utrecht, Netherlands
| | - Imo E Hoefer
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Leo Timmers
- Department of Cardiology, St. Antonius Hospital, Utrecht, Netherlands
| | - Saskia C A de Jager
- Department of Cardiology, Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
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8
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Kim SK, Biwer LA, Moss ME, Man JJ, Aronovitz MJ, Martin GL, Carrillo-Salinas FJ, Salvador AM, Alcaide P, Jaffe IZ. Mineralocorticoid Receptor in Smooth Muscle Contributes to Pressure Overload-Induced Heart Failure. Circ Heart Fail 2021; 14:e007279. [PMID: 33517669 PMCID: PMC7887087 DOI: 10.1161/circheartfailure.120.007279] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Mineralocorticoid receptor (MR) antagonists decrease heart failure (HF) hospitalization and mortality, but the mechanisms are unknown. Preclinical studies reveal that the benefits on cardiac remodeling and dysfunction are not completely explained by inhibition of MR in cardiomyocytes, fibroblasts, or endothelial cells. The role of MR in smooth muscle cells (SMCs) in HF has never been explored. METHODS Male mice with inducible deletion of MR from SMCs (SMC-MR-knockout) and their MR-intact littermates were exposed to HF induced by 27-gauge transverse aortic constriction versus sham surgery. HF phenotypes and mechanisms were measured 4 weeks later using cardiac ultrasound, intracardiac pressure measurements, exercise testing, histology, cardiac gene expression, and leukocyte flow cytometry. RESULTS Deletion of MR from SMC attenuated transverse aortic constriction-induced HF with statistically significant improvements in ejection fraction, cardiac stiffness, chamber dimensions, intracardiac pressure, pulmonary edema, and exercise capacity. Mechanistically, SMC-MR-knockout protected from adverse cardiac remodeling as evidenced by decreased cardiomyocyte hypertrophy and fetal gene expression, interstitial and perivascular fibrosis, and inflammatory and fibrotic gene expression. Exposure to pressure overload resulted in a statistically significant decline in cardiac capillary density and coronary flow reserve in MR-intact mice. These vascular parameters were improved in SMC-MR-knockout mice compared with MR-intact littermates exposed to transverse aortic constriction. CONCLUSIONS These results provide a novel paradigm by which MR inhibition may be beneficial in HF by blocking MR in SMC, thereby improving cardiac blood supply in the setting of pressure overload-induced hypertrophy, which in turn mitigates the adverse cardiac remodeling that contributes to HF progression and symptoms.
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MESH Headings
- Animals
- Aorta/surgery
- Arterial Pressure
- Cardiomegaly/genetics
- Cardiomegaly/pathology
- Cardiomegaly/physiopathology
- Constriction, Pathologic
- Disease Models, Animal
- Echocardiography
- Gene Knockout Techniques
- Heart Failure/diagnostic imaging
- Heart Failure/genetics
- Heart Failure/pathology
- Heart Failure/physiopathology
- Mice
- Muscle, Smooth, Vascular/metabolism
- Myocytes, Cardiac/metabolism
- Myocytes, Cardiac/pathology
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/pathology
- Myocytes, Smooth Muscle/physiology
- Receptors, Mineralocorticoid/genetics
- Ventricular Remodeling/genetics
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Affiliation(s)
- Seung Kyum Kim
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA
- Department of Sports Science, Seoul National University of Science and Technology, Seoul, Republic of Korea
| | - Lauren A. Biwer
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA
| | - M. Elizabeth Moss
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA
| | - Joshua J. Man
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA
| | - Mark J. Aronovitz
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA
| | - Gregory L. Martin
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA
| | | | - Ane M. Salvador
- Department of Immunology, Tufts University School of Medicine, Boston, MA
| | - Pilar Alcaide
- Department of Immunology, Tufts University School of Medicine, Boston, MA
| | - Iris Z. Jaffe
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA
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9
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Connelly KA, Zhang Y, Desjardins JF, Nghiem L, Visram A, Batchu SN, Yerra VG, Kabir G, Thai K, Advani A, Gilbert RE. Load-independent effects of empagliflozin contribute to improved cardiac function in experimental heart failure with reduced ejection fraction. Cardiovasc Diabetol 2020; 19:13. [PMID: 32035482 PMCID: PMC7007658 DOI: 10.1186/s12933-020-0994-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/26/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND AIMS Sodium-glucose linked cotransporter-2 (SGLT2) inhibitors reduce the likelihood of hospitalization for heart failure and cardiovascular death in both diabetic and non-diabetic individuals with reduced ejection fraction heart failure. Because SGLT2 inhibitors lead to volume contraction with reductions in both preload and afterload, these load-dependent factors are thought to be major contributors to the cardioprotective effects of the drug class. Beyond these effects, we hypothesized that SGLT2 inhibitors may also improve intrinsic cardiac function, independent of loading conditions. METHODS Pressure-volume (P-V) relationship analysis was used to elucidate changes in intrinsic cardiac function, independent of alterations in loading conditions in animals with experimental myocardial infarction, a well-established model of HFrEF. Ten-week old, non-diabetic Fischer F344 rats underwent ligation of the left anterior descending (LAD) coronary artery to induce myocardial infarction (MI) of the left ventricle (LV). Following confirmation of infarct size with echocardiography 1-week post MI, animals were randomized to receive vehicle, or the SGLT2 inhibitor, empagliflozin. Cardiac function was assessed by conductance catheterization just prior to termination 6 weeks later. RESULTS The circumferential extent of MI in animals that were subsequently randomized to vehicle or empagliflozin groups was similar. Empagliflozin did not affect fractional shortening (FS) as assessed by echocardiography. In contrast, load-insensitive measures of cardiac function were substantially improved with empagliflozin. Load-independent measures of cardiac contractility, preload recruitable stroke work (PRSW) and end-systolic pressure volume relationship (ESPVR) were higher in rats that had received empagliflozin. Consistent with enhanced cardiac performance in the heart failure setting, systolic blood pressure (SBP) was higher in rats that had received empagliflozin despite its diuretic effects. A trend to improved diastolic function, as evidenced by reduction in left ventricular end-diastolic pressure (LVEDP) was also seen with empagliflozin. MI animals treated with vehicle demonstrated myocyte hypertrophy, interstitial fibrosis and evidence for changes in key calcium handling proteins (all p < 0.05) that were not affected by empagliflozin therapy. CONCLUSION Empagliflozin therapy improves cardiac function independent of loading conditions. These findings suggest that its salutary effects are, at least in part, due to actions beyond a direct effect of reduced preload and afterload.
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Affiliation(s)
- Kim A Connelly
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 61 Queen Street East, Toronto, M5C 2T2, ON, Canada.
| | - Yanling Zhang
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 61 Queen Street East, Toronto, M5C 2T2, ON, Canada
| | - Jean-François Desjardins
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 61 Queen Street East, Toronto, M5C 2T2, ON, Canada
| | - Linda Nghiem
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 61 Queen Street East, Toronto, M5C 2T2, ON, Canada
| | - Aylin Visram
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 61 Queen Street East, Toronto, M5C 2T2, ON, Canada
| | - Sri N Batchu
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 61 Queen Street East, Toronto, M5C 2T2, ON, Canada
| | - Verra G Yerra
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 61 Queen Street East, Toronto, M5C 2T2, ON, Canada
| | - Golam Kabir
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 61 Queen Street East, Toronto, M5C 2T2, ON, Canada
| | - Kerri Thai
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 61 Queen Street East, Toronto, M5C 2T2, ON, Canada
| | - Andrew Advani
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 61 Queen Street East, Toronto, M5C 2T2, ON, Canada
| | - Richard E Gilbert
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 61 Queen Street East, Toronto, M5C 2T2, ON, Canada.
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10
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Considerations for Clinical Trials Targeting the Myocardial Interstitium. JACC Cardiovasc Imaging 2019; 12:2319-2331. [DOI: 10.1016/j.jcmg.2019.03.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/26/2019] [Accepted: 03/07/2019] [Indexed: 01/23/2023]
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11
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Bulluck H, Fröhlich GM, Nicholas JM, Mohdnazri S, Gamma R, Davies J, Sirker A, Mathur A, Blackman D, Garg P, Moon JC, Greenwood JP, Hausenloy DJ. Mineralocorticoid receptor antagonist pre-treatment and early post-treatment to minimize reperfusion injury after ST-elevation myocardial infarction: The MINIMIZE STEMI trial. Am Heart J 2019; 211:60-67. [PMID: 30893577 PMCID: PMC6483973 DOI: 10.1016/j.ahj.2019.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 02/11/2019] [Indexed: 01/28/2023]
Abstract
Background Mineralocorticoid receptor antagonist (MRA) therapy has been shown to prevent adverse left ventricular (LV) remodeling in ST-segment elevation myocardial infarction (STEMI) patients with heart failure. Whether initiating MRA therapy prior to primary percutaneous coronary intervention (PPCI) accrues additional benefit of reducing myocardial infarct size and preventing adverse LV remodeling is not known. We aimed to investigate whether MRA therapy initiated prior to reperfusion reduces myocardial infarct (MI) size and prevents adverse LV remodeling in STEMI patients. Methods STEMI patients presenting within 12 hours and with a proximal coronary artery occlusion with Thrombolysis In Myocardial Infarction flow grade 0 were consented and randomized to either an intravenous bolus of potassium canrenoate, followed by oral spironolactone for 3 months or matching placebo. The primary endpoint was MI size by cardiovascular magnetic resonance at 3 months. Results Sixty-seven patients completed the study. There was no significant difference in the final MI size at 3 months between the 2 groups (placebo: 17 ± 11%, MRA: 16 ± 10%, P = .574). There was also no difference in acute MI size (26 ± 16% versus 23 ± 14%, P = .425) or myocardial salvage (26 ± 12% versus 24 ± 8%, P = .456). At follow-up, there was a trend towards an improvement in LVEF (placebo: 49 ± 8%, MRA: 54 ± 11%, P = .053), and the MRA group had significantly greater percentage decrease in LVEDV (mean difference: −12.2 (95% CI −20.3 to −4.4)%, P = .003) and LVESV (mean difference: −18.2 (95% CI −30.1 to −6.3)%, P = .003). Conclusion This pilot study showed no benefit of MRA therapy in reducing MI size in STEMI patients when initiated prior to reperfusion, but there was an improvement in LV remodeling at 3 months. Adequately powered studies are warranted to confirm these findings.
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12
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Papademetriou V, Toumpourleka M, Imprialos KP, Alataki S, Manafis A, Stavropoulos K. The Role of Mineralocorticoid Receptor Antagonists in Heart Failure with Reduced Ejection Fraction. Curr Pharm Des 2019; 24:5517-5524. [DOI: 10.2174/1381612825666190219141326] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 02/13/2019] [Indexed: 12/20/2022]
Abstract
Background:
Heart failure (HF) is a worldwide modern epidemic, associated with significant morbidity
and mortality. Several causes have been identified for the syndrome, most of which share common pathophysiologic
pathways, including neurohormonal activation. Central to the latter lies activation of the reninangiotensin-
aldosterone system, and its effects on cardiovascular disease progression.
Objectives:
The aim of this review is to summarize the pathophysiology of aldosterone and the effects of its
blockage in the failing heart, as well as to provide state-of-the-art evidence, and address future perspectives regarding
the use of mineralocorticoid receptor antagonists in heart failure with reduced ejection fraction.
Method:
Literature was reviewed for studies that assess the pathophysiology of aldosterone in HF with reduced
ejection fraction (HFrEF), and the effects of mineralocorticoid receptor antagonists (MRAs) in this condition.
Results:
Several major society guidelines have synthesized the available evidence on HFrEF management, and
drugs that block the renin-angiotensin-aldosterone system at different levels continue to form the key component
of standard of care for these patients. Mineralocorticoid receptor antagonists are an important part of HFrEF
pharmacologic treatment, and their use is supported by a high level of evidence studies. This class of drugs demonstrated
significant benefits for morbidity and mortality, across the spectrum oh HFrEF, including patients after
acute myocardial infarction.
Conclusion:
Current evidence supports the central role of aldosterone in HFrEF progression, and the significant
benefits on outcomes with the use of MRAs.
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Affiliation(s)
| | - Maria Toumpourleka
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos P. Imprialos
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sofia Alataki
- Medical Clinic IV-Department of Cardiology, Manicipal Hospital Karlsruhe, Academic Teaching Hospital, University of Freiburg, Karlsruhe, Germany
| | - Alexandros Manafis
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Stavropoulos
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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13
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Xiang Y, Shi W, Li Z, Yang Y, Wang SY, Xiang R, Feng P, Wen L, Huang W. Efficacy and safety of spironolactone in the heart failure with mid-range ejection fraction and heart failure with preserved ejection fraction: A meta-analysis of randomized clinical trials. Medicine (Baltimore) 2019; 98:e14967. [PMID: 30921200 PMCID: PMC6456096 DOI: 10.1097/md.0000000000014967] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Recent studies have shown the efficacy for using spironolactone to treat heart failure with reduced ejection fraction (HFrEF), but the efficacy of spironolactone for heart failure with mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF) is unclear. This meta-analysis investigated the efficacy and safety of spironolactone in patients with HFmrEF and HFpEF. METHODS AND RESULTS We searched several databases including PubMed and the Cochrane Collaboration, for randomized controlled trials (RCTs) that assessed spironolactone treatment in HFmrEF and HFpEF. Eleven RCTs including 4539 patients were included. Spironolactone reduced hospitalizations (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.73-0.95; P = .006), improved New York Heart Association functional classifications (NYHA-FC) (OR, 0.35; 95% CI, 0.19-0.66; P = .001), decreased the levels of brain natriuretic peptide (BNP) (mean difference [MD], - 44.80 pg/mL; 95% CI, -73.44--16.17; P = .002), procollagen type I C-terminal propeptide (PICP) (MD, -27.04 ng/mL; 95% CI, -40.77--13.32, P < .001) in HFmrEF and HFpEF. Besides, it improved 6-minute walking distances (6-MWD) (standard weighted mean difference [SMD], 0.45 m; 95% CI, 0.27-0.64; P < .001), decreased amino-terminal peptide of procollagen type-III (PIIINP) (SMD, -0.37 μg/L; 95% CI, -0.59--0.15; P = .001) in HFpEF only. The risks of hyperkalemia (P<.001) and gynecomastia (P<.001) were increased. CONCLUSION Patients with HFmrEF and HFpEF could benefit from spironolactone treatment, with reduced hospitalizations, BNP levels, improved NYHA-FC, alleviated myocardial fibrosis by decreasing serum PICP in HFmrEF and HFpEF, decreased PIIINP levels and increased 6-MWD only in HFpEF. The risks of hyperkalemia and gynecomastia were significantly increased with the spironolactone treatment.
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Affiliation(s)
- Yajie Xiang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenhai Shi
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhuolin Li
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yunjing Yang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | | | - Rui Xiang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Panpan Feng
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Wen
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Huang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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14
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Salvador AM, Moss ME, Aronovitz M, Mueller KB, Blanton RM, Jaffe IZ, Alcaide P. Endothelial mineralocorticoid receptor contributes to systolic dysfunction induced by pressure overload without modulating cardiac hypertrophy or inflammation. Physiol Rep 2018. [PMID: 28637706 PMCID: PMC5492203 DOI: 10.14814/phy2.13313] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Heart Failure (HF) is associated with increased circulating levels of aldosterone and systemic inflammation. Mineralocorticoid receptor (MR) antagonists block aldosterone action and decrease mortality in patients with congestive HF. However, the molecular mechanisms underlying the therapeutic benefits of MR antagonists remain unclear. MR is expressed in all cell types in the heart, including the endothelial cells (EC), in which aldosterone induces the expression of intercellular adhesion molecule 1 (ICAM‐1). Recently, we reported that ICAM‐1 regulates cardiac inflammation and cardiac function in mice subjected to transverse aortic constriction (TAC). Whether MR specifically in endothelial cells (EC) contributes to the several mechanisms of pathological cardiac remodeling and cardiac dysfunction remains unclear. Basal cardiac function and LV dimensions were comparable in mice with MR selectively deleted from ECs (EC‐MR−/−) and wild‐type littermate controls (EC‐MR+/+). MR was specifically deleted in heart EC, and in EC‐containing tissues, but not in leukocytes of TAC EC‐MR−/− mice. While EC‐MR−/−TAC mice showed preserved systolic function and some alterations in the expression of fetal genes, the proinflammatory cytokine TNFα and the endothelin receptors in the LV as compared to EC‐MR+/+TAC mice, no difference was observed between both TAC groups in overall cardiac hypertrophy, ICAM‐1 LV expression and leukocyte infiltration, cardiac fibrosis or capillary rarefaction, all hallmarks of pathological cardiac remodeling. Our data indicate that EC‐MR contributes to the transition of cardiac hypertrophy to systolic dysfunction independently of other maladaptive changes induced by LV pressure overload.
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Affiliation(s)
- Ane M Salvador
- Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Boston, Massachusetts.,Centro de Investigaciόn Biomédica, Universidad de Granada, Spain
| | - M Elizabeth Moss
- Sackler School of Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts.,Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts
| | - Mark Aronovitz
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts
| | - Kathleen B Mueller
- Sackler School of Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts.,Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts
| | - Robert M Blanton
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts
| | - Iris Z Jaffe
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts
| | - Pilar Alcaide
- Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Boston, Massachusetts .,Sackler School of Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts
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15
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Gilbert EM, Xu WD. Rationales and choices for the treatment of patients with NYHA class II heart failure. Postgrad Med 2017; 129:619-631. [PMID: 28670961 DOI: 10.1080/00325481.2017.1344082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Heart failure (HF) in the United States represents a significant burden for patients and a tremendous strain on the healthcare system. Patients receiving a diagnosis of HF can be placed into 1 of 4 New York Heart Association (NYHA) functional classifications; the greatest proportion of patients are in the NYHA class II category, which is defined as patients having a slight limitation of physical activity but who are comfortable at rest, and for whom ordinary physical activity results in symptoms of HF. Because the severity of NYHA class II HF may be perceived as mild or unalarming by this definition, the urgency to treat this type of HF may be overlooked. However, these patients are optimal candidates for active intervention because their HF is at a critical point on the disease progression continuum when untoward changes can be halted or reversed. This review discusses the physiological consequences of NYHA class II HF with reduced ejection fraction and describes recent clinical trials that have demonstrated a therapeutic benefit for patients in this population. In doing so, we hope to establish that patients with NYHA class II disease merit careful attention and to provide reassurance to the treating community that options are available for these patients.
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Affiliation(s)
- Edward M Gilbert
- a Division of Cardiology , University of Utah , Salt Lake City , UT , USA
| | - Weining David Xu
- a Division of Cardiology , University of Utah , Salt Lake City , UT , USA
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16
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Vizzardi E, Pina PD, Caretta G, Bonadei I, Sciatti E, Lombardi C, D'Aloia A, Curnis A, Metra M. The effect of aldosterone-antagonist therapy on aortic elastic properties in patients with nonischemic dilated cardiomyopathy. J Cardiovasc Med (Hagerstown) 2016; 16:597-602. [PMID: 24978872 DOI: 10.2459/jcm.0000000000000102] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Many studies proved the prognostic importance of aortic stiffness as an independent predictor of cardiovascular morbidity and all-cause mortality. The decrease of arterial compliance has a high prevalence in patients with heart failure and affects both hemodynamics and prognosis. Aortic stiffness is partially caused by excessive activation of the renin-angiotensin-aldosterone system. Spironolactone, a mineralcorticoid receptor antagonist (MRA), has been shown to decrease aortic stiffness and fibrosis in experimental models. However, there are few studies that describe the effects of MRA on aortic stiffness in patients with nonischemic dilated cardiomyopathy. AIMS To evaluate the effect of spironolactone on aortic stiffness in patients with nonischemic dilated cardiomyopathy. MATERIALS AND METHODS We randomized (1 : 1) 102 patients with nonischemic dilated cardiomyopathy with New York Heart Association class I-II to receive spironolactone 25 mg/day (up to 100 mg/day) or placebo, in addition to recommended therapy. Aortic stiffness index, aortic strain, aortic distensibility and aortic dimensions were assessed at baseline and after 6 months. All measures were obtained with echocardiography M-mode at 3 cm above the aortic valve on parasternal long axis view and simultaneous brachial arterial pressure with sphygmomanometer. RESULTS Ascending aorta diameters, aortic stiffness index, aortic distensibility and aortic strain were similar at randomization in the two groups. After 6 months of therapy in the treated group, we found a reduction of aortic stiffness index (7.2 ± 3.5 versus 9.6 ± 4.8 mmHg; P = 0.03) and an increase of aortic distensibility (3.77 ± 1.0 versus 2.92 ± 0.55 mmHg; P = 0.01) and systolic aortic strain (10.0 ± 5.0 versus 8.0% ± 2.1%; P = 0.01). There were no difference in systolic arterial pressure, diastolic arterial pressure and differential pressure in the two groups. CONCLUSION Therapy with spironolactone is effective in reducing aortic stiffness in patients with nonischemic dilated cardiomyopathy. This effect could improve hemodynamics supporting the use of MRAs in patients with low New York Heart Association class (I-II).
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Affiliation(s)
- Enrico Vizzardi
- Section of Cardiovascular Diseases, Department of Medical and Surgical, Radiological Sciences and Public Health Specialties, University of Study of Brescia, Brescia, Italy
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17
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Bulluck H, Fröhlich GM, Mohdnazri S, Gamma RA, Davies JR, Clesham GJ, Sayer JW, Aggarwal RK, Tang KH, Kelly PA, Jagathesan R, Kabir A, Robinson NM, Sirker A, Mathur A, Blackman DJ, Ariti C, Krishnamurthy A, White SK, Meier P, Moon JC, Greenwood JP, Hausenloy DJ. Mineralocorticoid receptor antagonist pretreatment to MINIMISE reperfusion injury after ST-elevation myocardial infarction (the MINIMISE STEMI Trial): rationale and study design. Clin Cardiol 2016; 38:259-66. [PMID: 25990305 PMCID: PMC4489325 DOI: 10.1002/clc.22401] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 01/29/2015] [Accepted: 02/01/2015] [Indexed: 01/08/2023] Open
Abstract
Novel therapies capable of reducing myocardial infarct (MI) size when administered prior to reperfusion are required to prevent the onset of heart failure in ST‐segment elevation myocardial infarction (STEMI) patients treated by primary percutaneous coronary intervention (PPCI). Experimental animal studies have demonstrated that mineralocorticoid receptor antagonist (MRA) therapy administered prior to reperfusion can reduce MI size, and MRA therapy prevents adverse left ventricular (LV) remodeling in post‐MI patients with LV impairment. With these 2 benefits in mind, we hypothesize that initiating MRA therapy prior to PPCI, followed by 3 months of oral MRA therapy, will reduce MI size and prevent adverse LV remodeling in STEMI patients. The MINIMISE‐STEMI trial is a prospective, randomized, double‐blind, placebo‐controlled trial that will recruit 150 STEMI patients from four centers in the United Kingdom. Patients will be randomized to receive either an intravenous bolus of MRA therapy (potassium canrenoate 200 mg) or matching placebo prior to PPCI, followed by oral spironolactone 50 mg once daily or matching placebo for 3 months. A cardiac magnetic resonance imaging scan will be performed within 1 week of PPCI and repeated at 3 months to assess MI size and LV remodeling. Enzymatic MI size will be estimated by the 48‐hour area‐under‐the‐curve serum cardiac enzymes. The primary endpoint of the study will be MI size on the 3‐month cardiac magnetic resonance imaging scan. The MINIMISE STEMI trial will investigate whether early MRA therapy, initiated prior to reperfusion, can reduce MI size and prevent adverse post‐MI LV remodeling.
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Affiliation(s)
- Heerajnarain Bulluck
- Department of Cardiology, Heart Hospital, London, United Kingdom.,National Institute of Health Research, University College London Hospitals Biomedical Research Centre, London, United Kingdom.,Hatter Cardiovascular Institute, Institute of Cardiovascular Science, London, United Kingdom
| | - Georg M Fröhlich
- Department of Cardiology, Leeds General Infirmary, Leeds, United Kingdom.,Department of Cardiology, Essex Cardiothoracic Center, Nethermayne, Basildon, United Kingdom
| | - Shah Mohdnazri
- Department of Cardiology, Essex Cardiothoracic Center, Nethermayne, Basildon, United Kingdom
| | - Reto A Gamma
- Department of Cardiology, Essex Cardiothoracic Center, Nethermayne, Basildon, United Kingdom
| | - John R Davies
- Department of Cardiology, Essex Cardiothoracic Center, Nethermayne, Basildon, United Kingdom
| | - Gerald J Clesham
- Department of Cardiology, Essex Cardiothoracic Center, Nethermayne, Basildon, United Kingdom
| | - Jeremy W Sayer
- Department of Cardiology, Essex Cardiothoracic Center, Nethermayne, Basildon, United Kingdom
| | - Rajesh K Aggarwal
- Department of Cardiology, Essex Cardiothoracic Center, Nethermayne, Basildon, United Kingdom
| | - Kare H Tang
- Department of Cardiology, Essex Cardiothoracic Center, Nethermayne, Basildon, United Kingdom
| | - Paul A Kelly
- Department of Cardiology, Essex Cardiothoracic Center, Nethermayne, Basildon, United Kingdom
| | - Rohan Jagathesan
- Department of Cardiology, Essex Cardiothoracic Center, Nethermayne, Basildon, United Kingdom
| | - Alamgir Kabir
- Department of Cardiology, Essex Cardiothoracic Center, Nethermayne, Basildon, United Kingdom
| | - Nicholas M Robinson
- Department of Cardiology, Essex Cardiothoracic Center, Nethermayne, Basildon, United Kingdom
| | - Alex Sirker
- Department of Cardiology, Heart Hospital, London, United Kingdom
| | - Anthony Mathur
- London Department of Cardiology, Chest Hospital, London, United Kingdom
| | - Daniel J Blackman
- Department of Cardiology, Leeds General Infirmary, Leeds, United Kingdom
| | - Cono Ariti
- Nuffield Health Trust, London, United Kingdom.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Steven K White
- Department of Cardiology, Heart Hospital, London, United Kingdom.,National Institute of Health Research, University College London Hospitals Biomedical Research Centre, London, United Kingdom.,Hatter Cardiovascular Institute, Institute of Cardiovascular Science, London, United Kingdom
| | - Pascal Meier
- Department of Cardiology, Heart Hospital, London, United Kingdom
| | - James C Moon
- Department of Cardiology, Heart Hospital, London, United Kingdom.,National Institute of Health Research, University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - John P Greenwood
- Department of Cardiology, Leeds General Infirmary, Leeds, United Kingdom
| | - Derek J Hausenloy
- National Institute of Health Research, University College London Hospitals Biomedical Research Centre, London, United Kingdom.,Hatter Cardiovascular Institute, Institute of Cardiovascular Science, London, United Kingdom.,Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore, Singapore.,National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore
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18
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Miller WL, Jaffe AS. Biomarkers in heart failure: the importance of inconvenient details. ESC Heart Fail 2016; 3:3-10. [PMID: 27774262 PMCID: PMC5063139 DOI: 10.1002/ehf2.12071] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 08/26/2015] [Accepted: 09/21/2015] [Indexed: 12/22/2022] Open
Abstract
The proliferation of cardiac-related biomarkers and advocacy for their use has often come without adequate discussion of limitations in the interpretation of values and their best use in heart failure (HF) patients to provide a balanced assessment of how cardiac biomarkers are advocated for use in HF and areas where we would argue there are no gaps in knowledge. We include suggestions to address these issues. We have focused on peer-reviewed publications over the period 2000 to present. Most studies have used samples at one or at most two points in time to define risk. Although biomarkers might add to the magnitude of risk, it is unclear how often they lead to changes in treatment. We suggest that defining the use of serial biomarker testing over time would be more helpful. To do this, it is necessary to take into account the biomarker's analytical and biological variability in addition to its ability to define and monitor therapy. These factors are often overlooked leading to conclusions that may be statistically significant but not clinically or analytically robust. An appreciation of the value and limitations of biomarker use is important to all clinicians who manage HF patients. If the proper studies are done so that biomarkers are used optimally, they will likely be helpful in defining when and how to intervene. If we continue as we have, we will continue to have ambiguity about the use of these valuable probes in the assessment and management of HF.
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Affiliation(s)
- Wayne L. Miller
- Division of Cardiovascular DiseasesMayo ClinicRochesterMNUSA
| | - Allan S. Jaffe
- Division of Cardiovascular DiseasesMayo ClinicRochesterMNUSA
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Le HH, El-Khatib C, Mombled M, Guitarian F, Al-Gobari M, Fall M, Janiaud P, Marchant I, Cucherat M, Bejan-Angoulvant T, Gueyffier F. Impact of Aldosterone Antagonists on Sudden Cardiac Death Prevention in Heart Failure and Post-Myocardial Infarction Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. PLoS One 2016; 11:e0145958. [PMID: 26891235 PMCID: PMC4758660 DOI: 10.1371/journal.pone.0145958] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 12/10/2015] [Indexed: 01/06/2023] Open
Abstract
Background and Objectives Sudden cardiac death (SCD) is a severe burden of modern medicine. Aldosterone antagonist is publicized as effective in reducing mortality in patients with heart failure (HF) or post myocardial infarction (MI). Our study aimed to assess the efficacy of AAs on mortality including SCD, hospitalization admission and several common adverse effects. Methods We searched Embase, PubMed, Web of Science, Cochrane library and clinicaltrial.gov for randomized controlled trials (RCTs) assigning AAs in patients with HF or post MI through May 2015. The comparator included standard medication or placebo, or both. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Event rates were compared using a random effects model. Prospective RCTs of AAs with durations of at least 8 weeks were selected if they included at least one of the following outcomes: SCD, all-cause/cardiovascular mortality, all-cause/cardiovascular hospitalization and common side effects (hyperkalemia, renal function degradation and gynecomastia). Results Data from 19,333 patients enrolled in 25 trials were included. In patients with HF, this treatment significantly reduced the risk of SCD by 19% (RR 0.81; 95% CI, 0.67–0.98; p = 0.03); all-cause mortality by 19% (RR 0.81; 95% CI, 0.74–0.88, p<0.00001) and cardiovascular death by 21% (RR 0.79; 95% CI, 0.70–0.89, p<0.00001). In patients with post-MI, the matching reduced risks were 20% (RR 0.80; 95% CI, 0.66–0.98; p = 0.03), 15% (RR 0.85; 95% CI, 0.76–0.95, p = 0.003) and 17% (RR 0.83; 95% CI, 0.74–0.94, p = 0.003), respectively. Concerning both subgroups, the relative risks respectively decreased by 19% (RR 0.81; 95% CI, 0.71–0.92; p = 0.002) for SCD, 18% (RR 0.82; 95% CI, 0.77–0.88, p < 0.0001) for all-cause mortality and 20% (RR 0.80; 95% CI, 0.74–0.87, p < 0.0001) for cardiovascular mortality in patients treated with AAs. As well, hospitalizations were significantly reduced, while common adverse effects were significantly increased. Conclusion Aldosterone antagonists appear to be effective in reducing SCD and other mortality events, compared with placebo or standard medication in patients with HF and/or after a MI.
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Affiliation(s)
- Hai-Ha Le
- Laboratoire de Biologie et Biométrie Evolutive - Equipe Modélisation des Effets Thérapeutiques, UMR 5558 Université Claude Bernard Lyon1, Lyon, France
| | - Chadia El-Khatib
- Laboratoire de Biologie et Biométrie Evolutive - Equipe Modélisation des Effets Thérapeutiques, UMR 5558 Université Claude Bernard Lyon1, Lyon, France
| | - Margaux Mombled
- Laboratoire de Biologie et Biométrie Evolutive - Equipe Modélisation des Effets Thérapeutiques, UMR 5558 Université Claude Bernard Lyon1, Lyon, France
| | - Frédéric Guitarian
- Laboratoire de Biologie et Biométrie Evolutive - Equipe Modélisation des Effets Thérapeutiques, UMR 5558 Université Claude Bernard Lyon1, Lyon, France
| | - Muaamar Al-Gobari
- Lausanne University Hospital (CHUV), Institute of social & preventive medicine (IUMSP), Lausanne, Switzerland
| | - Mor Fall
- Laboratoire de Biologie et Biométrie Evolutive - Equipe Modélisation des Effets Thérapeutiques, UMR 5558 Université Claude Bernard Lyon1, Lyon, France
| | - Perrine Janiaud
- Laboratoire de Biologie et Biométrie Evolutive - Equipe Modélisation des Effets Thérapeutiques, UMR 5558 Université Claude Bernard Lyon1, Lyon, France
| | - Ivanny Marchant
- Escuela de Medicina, Departamento de Pre-clínicas, Universidad de Valparaíso, Valparaíso, Chile
| | - Michel Cucherat
- Laboratoire de Biologie et Biométrie Evolutive - Equipe Modélisation des Effets Thérapeutiques, UMR 5558 Université Claude Bernard Lyon1, Lyon, France
| | - Théodora Bejan-Angoulvant
- CHRU de Tours, Service de Pharmacologie Clinique, Hôpital Bretonneau, Tours, France
- CNRS UMR 7292, Tours, France
- Université François-Rabelais, GICC, Tours, France
| | - François Gueyffier
- Laboratoire de Biologie et Biométrie Evolutive - Equipe Modélisation des Effets Thérapeutiques, UMR 5558 Université Claude Bernard Lyon1, Lyon, France
- Service de Pharmacologie Clinique et essais thérapeutiques, Hospices Civils de Lyon, Lyon, France
- * E-mail:
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Pandey A, Garg S, Matulevicius SA, Shah AM, Garg J, Drazner MH, Amin A, Berry JD, Marwick TH, Marso SP, de Lemos JA, Kumbhani DJ. Effect of Mineralocorticoid Receptor Antagonists on Cardiac Structure and Function in Patients With Diastolic Dysfunction and Heart Failure With Preserved Ejection Fraction: A Meta-Analysis and Systematic Review. J Am Heart Assoc 2015; 4:e002137. [PMID: 26459931 PMCID: PMC4845109 DOI: 10.1161/jaha.115.002137] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 07/28/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND There has been an increasing interest in use of mineralocorticoid receptor antagonists (MRAs) in patients with heart failure with preserved ejection fraction (HFPEF). However, a comprehensive evaluation of MRA effects on left ventricular (LV) structure and function in these patients is lacking. In this meta-analysis, we evaluated the effects of MRAs on LV structure and function among patients with diastolic dysfunction or HFPEF. METHODS & RESULTS Randomized, controlled clinical trials evaluating the efficacy of MRAs in patients with diastolic dysfunction or HFPEF were included. The primary outcome was change in E/e', a specific measure of diastolic function. Secondary outcomes included changes in other measures of diastolic function, LV structure, surrogate markers for myocardial fibrosis (carboxy-terminal peptide of procollagen type I [PICP] and amino-terminal peptide of pro-collagen type-II [PIIINP]), blood pressure, and exercise tolerance. In the pooled analysis, MRA use was associated with significant reduction in E/e' (weighted mean difference [WMD] [95% confidence interval {CI}]: -1.68 [-2.03 to -1.33]; P<0.0001) and deceleration time (WMD [95% CI]: -12.0 ms [-23.3 to -0.7]; P=0.04) as compared with control, suggesting and improvement in diastolic function. Furthermore, blood pressure and levels of PIIINP and PICP were also significantly reduced with MRA therapy with no significant change in LV mass or dimensions. CONCLUSION MRA therapy in patients with asymptomatic diastolic dysfunction or HFPEF is associated with significant improvement in diastolic function and markers of cardiac fibrosis without a significant change in LV mass or dimensions.
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Affiliation(s)
| | - Sushil Garg
- University of Minnesota Medical CenterMinneapolisMNAustralia
| | | | | | - Jalaj Garg
- New York Medical CenterValhallaNYAustralia
| | | | - Alpesh Amin
- UT Southwestern Medical CenterDallasTXAustralia
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Mancini GJ, Howlett JG, Borer J, Liu PP, Mehra MR, Pfeffer M, Swedberg K, Tardif JC. Pharmacologic Options for the Management of Systolic Heart Failure: Examining Underlying Mechanisms. Can J Cardiol 2015; 31:1282-92. [DOI: 10.1016/j.cjca.2015.02.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 02/16/2015] [Accepted: 02/16/2015] [Indexed: 01/19/2023] Open
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Raman SV, Hor KN, Mazur W, Halnon NJ, Kissel JT, He X, Tran T, Smart S, McCarthy B, Taylor MD, Jefferies JL, Rafael-Fortney JA, Lowe J, Roble SL, Cripe LH. Eplerenone for early cardiomyopathy in Duchenne muscular dystrophy: a randomised, double-blind, placebo-controlled trial. Lancet Neurol 2015; 14:153-61. [PMID: 25554404 PMCID: PMC4361281 DOI: 10.1016/s1474-4422(14)70318-7] [Citation(s) in RCA: 161] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cardiomyopathy is a leading cause of death in patients with Duchenne muscular dystrophy and myocardial damage precedes decline in left ventricular systolic function. We tested the efficacy of eplerenone on top of background therapy in patients with Duchenne muscular dystrophy with early myocardial disease. METHODS In this randomised, double-blind, placebo-controlled trial, boys from three centres in the USA aged 7 years or older with Duchenne muscular dystrophy, myocardial damage by late gadolinium enhancement cardiac MRI and preserved ejection fraction received either eplerenone 25 mg or placebo orally, every other day for the first month and once daily thereafter, in addition to background clinician-directed therapy with either angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB). Computer-generated randomisation was done centrally using block sizes of four and six, and only the study statistician and the investigational pharmacy had the preset randomisation assignments. The primary outcome was change in left ventricular circumferential strain (Ecc) at 12 months, a measure of contractile dysfunction. Safety was established through serial serum potassium levels and measurement of cystatin C, a non-creatinine measure of kidney function. This trial is registered with ClinicalTrials.gov, number NCT01521546. FINDINGS Between Jan 26, 2012, and July 3, 2013, 188 boys were screened and 42 were enrolled. 20 were randomly assigned to receive eplerenone and 22 to receive placebo, of whom 20 in the eplerenone group and 20 in the placebo group completed baseline, 6-month, and 12-month visits. After 12 months, decline in left ventricular circumferential strain was less in those who received eplerenone than in those who received placebo (median ΔEcc 1·0 [IQR 0·3-2·2] vs 2·2 [1·3-3·1]; p=0·020). Cystatin C concentrations remained normal in both groups, and all non-haemolysed blood samples showed normal potassium concentrations. One 23-year-old patient in the placebo group died of fat embolism, and another patient in the placebo group withdrew from the trial to address long-standing digestive issues. All other adverse events were mild: short-lived headaches coincident with seasonal allergies occurred in one patient given eplerenone, flushing occurred in one patient given placebo, and anxiety occurred in another patient given placebo. INTERPRETATION In boys with Duchenne muscular dystrophy and preserved ejection fraction, addition of eplerenone to background ACEI or ARB therapy attenuates the progressive decline in left ventricular systolic function. Early use of available drugs warrants consideration in this population at high risk of cardiac death, but further studies are needed to determine the effect of combination cardioprotective therapy on event-free survival in Duchenne muscular dystrophy. FUNDING BallouSkies, Parent Project for Muscular Dystrophy, US National Center for Advancing Translational Sciences, and US National Institutes of Health.
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Affiliation(s)
- Subha V Raman
- Ohio State University Davis Heart and Lung Research Institute, Columbus, OH, USA.
| | - Kan N Hor
- Nationwide Children's Hospital, Columbus, OH, USA
| | - Wojciech Mazur
- The Christ Hospital Heart and Vascular Center, Cincinnati, OH, USA
| | - Nancy J Halnon
- Department of Pediatrics, University of California Los Angeles, Los Angeles, CA, USA
| | - John T Kissel
- Department of Neurology, Ohio State University, Columbus, OH, USA
| | - Xin He
- Department of Epidemiology and Biostatistics, University of Maryland, MD, USA
| | - Tam Tran
- Ohio State University Davis Heart and Lung Research Institute, Columbus, OH, USA
| | - Suzanne Smart
- Ohio State University Davis Heart and Lung Research Institute, Columbus, OH, USA
| | - Beth McCarthy
- Ohio State University Davis Heart and Lung Research Institute, Columbus, OH, USA
| | - Michael D Taylor
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - John L Jefferies
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Jeovanna Lowe
- Ohio State University Davis Heart and Lung Research Institute, Columbus, OH, USA
| | - Sharon L Roble
- Ohio State University Davis Heart and Lung Research Institute, Columbus, OH, USA; Nationwide Children's Hospital, Columbus, OH, USA
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Chen Y, Wang H, Lu Y, Huang X, Liao Y, Bin J. Effects of mineralocorticoid receptor antagonists in patients with preserved ejection fraction: a meta-analysis of randomized clinical trials. BMC Med 2015; 13:10. [PMID: 25598008 PMCID: PMC4307751 DOI: 10.1186/s12916-014-0261-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 12/17/2014] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Mineralocorticoid receptor antagonists (MRAs) have been shown to be effective in patients with heart failure or myocardial infarction complicated by a reduced ejection fraction. However, the role of MRAs in patients with preserved ejection fraction (PEF) remains to be clarified. We aimed to summarize the evidence for the efficacy of MRAs in patients with either heart failure with PEF (HF-PEF) or myocardial infarction with PEF (MI-PEF). METHODS We searched PubMed, EMBASE, Cochrane Library, and clinical trials databases for randomized controlled trials, through June 2014, assessing MRA treatment in HF-PEF or MI-PEF patients. Fourteen randomized controlled trials (MI-PEF, 5; HF-PEF, 9; n = 6,428 patients) were included. RESULTS MRA treatment reduced the risk of hospitalization for heart failure (relative risk, 0.83; 95% confidence interval [CI], 0.70 to 0.98), improved quality of life (weighted mean difference [WMD], -5.16; 95% CI, -8.03 to -2.30), left ventricular end-diastolic diameter (standardized mean difference, -0.21; 95% CI, 0.32 to -0.11), and serum amino-terminal peptide of procollagen type-III level (WMD, -1.50, 95% CI, -1.72 to -1.29) in patients with PEF. In addition, MRAs reduced E/e'(an echocardiographic estimate of filling pressure for assessment of diastolic function; WMD, -1.82; 95% CI, -2.23 to -1.42) in HF-PEF patients and E/A ratio (the ratio of early to late diastolic transmitral flow; WMD, 0.12; 95% CI, 0.10 to 0.14) in MI-PEF patients. However, all-cause mortality was not improved by MRAs in either HF-PEF (P = 0.90) or MI-PEF (P = 0.27) patients. CONCLUSIONS MRA treatment in PEF patients led to reduced hospitalization for heart failure, quantifiable improvements in quality of life and diastolic function, and reversal of cardiac remodeling, but did not provide any all-cause mortality benefit.
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Affiliation(s)
- Yanmei Chen
- State Key Lab for Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China.
| | - He Wang
- State Key Lab for Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China.
| | - Yongkang Lu
- State Key Lab for Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China.
| | - Xiaobo Huang
- State Key Lab for Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China.
| | - Yulin Liao
- State Key Lab for Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China.
| | - Jianping Bin
- State Key Lab for Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China.
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Effect of aldosterone antagonists on blood pressure in patients with resistant hypertension: a meta-analysis. J Hum Hypertens 2014; 29:159-66. [DOI: 10.1038/jhh.2014.64] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 06/14/2014] [Accepted: 06/30/2014] [Indexed: 11/09/2022]
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Vizzardi E, Regazzoni V, Caretta G, Gavazzoni M, Sciatti E, Bonadei I, Trichaki E, Raddino R, Metra M. Mineralocorticoid receptor antagonist in heart failure: Past, present and future perspectives. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VESSELS 2014; 3:6-14. [PMID: 29450163 PMCID: PMC5801434 DOI: 10.1016/j.ijchv.2014.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 03/08/2014] [Indexed: 12/24/2022]
Abstract
Aldosterone is involved in various deleterious effects on the cardiovascular system, including sodium and fluid retention, myocardial fibrosis, vascular stiffening, endothelial dysfunction, catecholamine release and stimulation of cardiac arrhythmias. Therefore, aldosterone receptor blockade may have several potential benefits in patients with cardiovascular disease. Mineralocorticoid receptor antagonists (MRAs) have been shown to prevent many of the maladaptive effects of aldosterone, in particular among patients with heart failure (HF). Randomized controlled trials have demonstrated efficacy of MRA in heart failure with reduced ejection fraction, both in patients with NYHA functional classes III and IV and in asymptomatic and mildly symptomatic patients (NYHA classes I and II). Recent data in patients with heart failure with preserved ejection fraction are encouraging. MRA could also have anti-arrhythmic effects on atrial and ventricular arrhythmias and may be helpful in patient ischemic heart disease through prevention of myocardial fibrosis and vascular damage. This article aims to discuss the pathophysiological effects of aldosterone in patients with cardiovascular disease and to review the current data that support the use of MRA in heart failure.
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Affiliation(s)
- Enrico Vizzardi
- Corresponding author. Tel.: + 39 303995679; fax: + 39 303996801Corresponding author.Tel.: + 39 303995679; fax: + 39 303996801
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van den Berg TNA, Rongen GA, Fröhlich GM, Deinum J, Hausenloy DJ, Riksen NP. The cardioprotective effects of mineralocorticoid receptor antagonists. Pharmacol Ther 2013; 142:72-87. [PMID: 24275323 DOI: 10.1016/j.pharmthera.2013.11.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 11/04/2013] [Indexed: 01/14/2023]
Abstract
Despite state-of-the-art reperfusion therapy, morbidity and mortality remain significant in patients with an acute myocardial infarction. Therefore, novel strategies to limit myocardial ischemia-reperfusion injury are urgently needed. Mineralocorticoid receptor (MR) antagonists are attractive candidates for this purpose, since several clinical trials in patients with heart failure have reported a survival benefit with MR antagonist treatment. MRs are expressed by several cells of the cardiovascular system, including cardiomyocytes, cardiac fibroblasts, vascular smooth muscle cells, and endothelial cells. Experiments in animal models of myocardial infarction have demonstrated that acute administration of MR antagonists, either before ischemia or immediately at the moment of coronary reperfusion, limits infarct size. This action appears to be independent of the presence of aldosterone and cortisol, which are the endogenous ligands for the MR. The cardioprotective effect is mediated by a nongenomic intracellular signaling pathway, including adenosine receptor stimulation, and activation of several components of the Reperfusion Injury Salvage Kinase (RISK) pathway. In addition to limiting infarct size, MR antagonists can improve scar healing when administered shortly after reperfusion and can reduce cardiac remodeling post myocardial infarction. Clinical trials are currently being performed studying whether early administration of MR antagonists can indeed improve prognosis in patients with an acute myocardial infarction, independent of the presence of heart failure.
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Affiliation(s)
- T N A van den Berg
- Department of Pharmacology and Toxicology, Radboud University Medical Centre, Nijmegen, the Netherlands; Department of General Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Gerard A Rongen
- Department of Pharmacology and Toxicology, Radboud University Medical Centre, Nijmegen, the Netherlands; Department of General Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Georg M Fröhlich
- The Hatter Cardiovascular Institute, University College London, United Kingdom
| | - Jaap Deinum
- Department of General Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Derek J Hausenloy
- The Hatter Cardiovascular Institute, University College London, United Kingdom
| | - Niels P Riksen
- Department of Pharmacology and Toxicology, Radboud University Medical Centre, Nijmegen, the Netherlands; Department of General Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands.
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Minicucci MF, dos Santos PP, Rafacho BPM, Gonçalves AF, Silva RAC, Chiuso-Minicucci F, Azevedo PS, Polegato BF, Okoshi K, Pereira EJ, Paiva SAR, Zornoff LAM. Mechanisms involved in the beneficial effects of spironolactone after myocardial infarction. PLoS One 2013; 8:e76866. [PMID: 24098808 PMCID: PMC3786966 DOI: 10.1371/journal.pone.0076866] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 08/23/2013] [Indexed: 11/18/2022] Open
Abstract
Introduction Our objective was to analyze the effect of spironolactone on cardiac remodeling after experimental myocardial infarction (MI), assessed by matricellular proteins levels, cardiac collagen amount and distribution, myocardial tissue metalloproteinase inhibitor-1(TIMP-1) concentration, myocyte hypertrophy, left ventricular architecture, and invitro and invivo cardiac function. Methods Wistar rats were assigned to 4 groups: control group, in which animals were submitted to simulated surgery (SHAM group; n=9); group that received spironolactone and in which animals were submitted to simulated surgery (SHAM-S group, n=9); myocardial infarction group, in which animals were submitted to coronary artery ligation (MI group, n=15); and myocardial infarction group with spironolactone supplementation (MI-S group, n=15). The rats were observed for 3 months. Results The MI group had higher values of left cardiac chambers and mass index and lower relative wall thicknesses compared with the SHAM group. In addition, diastolic and systolic functions were worse in the MI groups. However, spironolactone did not influence any of these variables. The MI-S group had a lower myocardial hydroxyproline concentration and myocyte cross-sectional area compared with the MI group. Myocardial periostin and collagen type III were lower in the MI-S group compared with the MI-group. In addition, TIMP-1 concentration in myocardium was higher in the MI-S group compared with the MI group. Conclusions The predominant consequence of spironolactone supplementation after MI is related to reductions in collagens, with discrete attenuation of other remodeling variables. Importantly, this effect may be modulated by periostin and TIMP-1 levels.
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Affiliation(s)
- Marcos F. Minicucci
- Internal Medicine Department, Botucatu Medical School, University Estadual Paulista, Botucatu, São Paulo, Brazil
- * E-mail:
| | - Priscila P. dos Santos
- Internal Medicine Department, Botucatu Medical School, University Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Bruna P. M. Rafacho
- Internal Medicine Department, Botucatu Medical School, University Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Andrea F. Gonçalves
- Internal Medicine Department, Botucatu Medical School, University Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Renata A. C. Silva
- Internal Medicine Department, Botucatu Medical School, University Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Fernanda Chiuso-Minicucci
- Department of Microbiology and Immunology, Institute of Biosciences, University Estadual, Paulista, Botucatu, São Paulo, Brazil
| | - Paula S. Azevedo
- Internal Medicine Department, Botucatu Medical School, University Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Bertha F. Polegato
- Internal Medicine Department, Botucatu Medical School, University Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Katashi Okoshi
- Internal Medicine Department, Botucatu Medical School, University Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Elenize J. Pereira
- Internal Medicine Department, Botucatu Medical School, University Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Sergio A. R. Paiva
- Internal Medicine Department, Botucatu Medical School, University Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Leonardo A. M. Zornoff
- Internal Medicine Department, Botucatu Medical School, University Estadual Paulista, Botucatu, São Paulo, Brazil
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