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Simões JLB, Braga GDC, Mittelmann TH, Bagatini MD. Current Pharmacology and Modulation of the Purinergic System in Takotsubo Syndrome Triggered by Cytokine Storm. Curr Probl Cardiol 2024; 49:102019. [PMID: 37544631 DOI: 10.1016/j.cpcardiol.2023.102019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
Studies show that with the COVID-19 pandemic, the world's population went through multiple stress and anxiety factors, generating serious psychological problems, in addition, the virus also caused damage and physical stress to those contaminated. In this way, the intense emotional experiences and stressful effects on the body caused by SARS-CoV-2 are capable of triggering the excessive release of catecholamines in the body. Thus, the framework of Takotsubo Syndrome is characterized by myocardial dysfunction as a response of cardiac receptors to the spillage of such hormones in an unregulated way in the human body. The purinergic system plays a central role in this process, as it actively participates in actions responsible for the syndromic cascade, such as the stress generated by the cytokine storm triggered by the virus and the stimulation of deregulated catecholamine release. Therefore, further pharmacological studies on the role of purines in this pathology should be developed in order to avoid the evolution of the syndrome and to modulate its P1 and P2 receptors aiming at developing means of reversing or treating the Takotsubo Syndrome.
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Sridharan D, Pracha N, Rana SJ, Ahmed S, Dewani AJ, Alvi SB, Mergaye M, Ahmed U, Khan M. Preclinical Large Animal Porcine Models for Cardiac Regeneration and Its Clinical Translation: Role of hiPSC-Derived Cardiomyocytes. Cells 2023; 12:cells12071090. [PMID: 37048163 PMCID: PMC10093073 DOI: 10.3390/cells12071090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/14/2023] Open
Abstract
Myocardial Infarction (MI) occurs due to a blockage in the coronary artery resulting in ischemia and necrosis of cardiomyocytes in the left ventricular heart muscle. The dying cardiac tissue is replaced with fibrous scar tissue, causing a decrease in myocardial contractility and thus affecting the functional capacity of the myocardium. Treatments, such as stent placements, cardiac bypasses, or transplants are beneficial but with many limitations, and may decrease the overall life expectancy due to related complications. In recent years, with the advent of human induced pluripotent stem cells (hiPSCs), newer avenues using cell-based approaches for the treatment of MI have emerged as a potential for cardiac regeneration. While hiPSCs and their derived differentiated cells are promising candidates, their translatability for clinical applications has been hindered due to poor preclinical reproducibility. Various preclinical animal models for MI, ranging from mice to non-human primates, have been adopted in cardiovascular research to mimic MI in humans. Therefore, a comprehensive literature review was essential to elucidate the factors affecting the reproducibility and translatability of large animal models. In this review article, we have discussed different animal models available for studying stem-cell transplantation in cardiovascular applications, mainly focusing on the highly translatable porcine MI model.
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Affiliation(s)
- Divya Sridharan
- Department of Emergency Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Nooruddin Pracha
- Department of Emergency Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Schaza Javed Rana
- Department of Emergency Medicine, The Ohio State University, Columbus, OH 43210, USA
- Department of Internal Medicine, Northeast Georgia Medical Center, Gainesville, GA 30501, USA
| | - Salmman Ahmed
- Department of Emergency Medicine, The Ohio State University, Columbus, OH 43210, USA
- Lake Erie College of Osteopathic Medicine (LECOM), Erie, PA 16509, USA
| | - Anam J Dewani
- Department of Emergency Medicine, The Ohio State University, Columbus, OH 43210, USA
- Department of Chemistry & Biochemistry, The University of Toledo, Toledo, OH 43606, USA
| | - Syed Baseeruddin Alvi
- Department of Emergency Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Muhamad Mergaye
- Department of Emergency Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Uzair Ahmed
- Department of Emergency Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Mahmood Khan
- Department of Emergency Medicine, The Ohio State University, Columbus, OH 43210, USA
- Department of Physiology and Cell Biology, The Ohio State University, Columbus, OH 43210, USA
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3
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Xing Z, Chen J, Yu T, Li X, Dong W, Peng C, Li D. Aconitum carmichaelii Debx. Attenuates Heart Failure through Inhibiting Inflammation and Abnormal Vascular Remodeling. Int J Mol Sci 2023; 24:ijms24065838. [PMID: 36982912 PMCID: PMC10059042 DOI: 10.3390/ijms24065838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
Heart failure (HF) is the most common complication following myocardial infarction, closely associated with ventricular remodeling. Aconitum carmichaelii Debx., a traditional Chinese herb, possesses therapeutic effects on HF and related cardiac diseases. However, its effects and mechanisms on HF-associated cardiac diseases are still unclear. In the present study, a water extraction of toasted Aconitum carmichaelii Debx. (WETA) was verified using UPLC-Q/TOF-MS. The heart function of HF rats was assessed by echocardiography and strain analysis, and myocardial injury was measured by serum levels of CK-MB, cTnT, and cTnI. The pathological changes of cardiac tissues were evaluated by 2,3,5-triphenyltetrazolium chloride (TTC) staining, hematoxylin and eosin (H&E) staining, and Masson's trichrome staining. Additionally, the levels of inflammation-related genes and proteins and components related to vascular remodeling were detected by RT-qPCR, Western blot, and immunofluorescence. WETA significantly inhibited the changes in echocardiographic parameters and the increase in heart weight, cardiac infarction size, the myonecrosis, edema, and infiltration of inflammatory cells, collagen deposition in heart tissues, and also mitigated the elevated serum levels of CK-MB, cTnT, and cTnI in ISO-induced rats. Additionally, WETA suppressed the expressions of inflammatory genes, including IL-1β, IL-6, and TNF-α and vascular injury-related genes, such as VCAM1, ICAM1, ANP, BNP, and MHC in heart tissues of ISO-induced HF rats, which were further confirmed by Western blotting and immunofluorescence. In summary, the myocardial protective effect of WETA was conferred through inhibiting inflammatory responses and abnormal vascular remodeling in ISO-treated rats.
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Affiliation(s)
- Ziwei Xing
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Junren Chen
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Tingting Yu
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Xu Li
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Wei Dong
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Cheng Peng
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Dan Li
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
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Gonçalves PR, Nascimento LD, Gerlach RF, Rodrigues KE, Prado AF. Matrix Metalloproteinase 2 as a Pharmacological Target in Heart Failure. Pharmaceuticals (Basel) 2022; 15:ph15080920. [PMID: 35893744 PMCID: PMC9331741 DOI: 10.3390/ph15080920] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/11/2022] [Accepted: 07/11/2022] [Indexed: 12/18/2022] Open
Abstract
Heart failure (HF) is an acute or chronic clinical syndrome that results in a decrease in cardiac output and an increase in intracardiac pressure at rest or upon exertion. The pathophysiology of HF is heterogeneous and results from an initial harmful event in the heart that promotes neurohormonal changes such as autonomic dysfunction and activation of the renin-angiotensin-aldosterone system, endothelial dysfunction, and inflammation. Cardiac remodeling occurs, which is associated with degradation and disorganized synthesis of extracellular matrix (ECM) components that are controlled by ECM metalloproteinases (MMPs). MMP-2 is part of this group of proteases, which are classified as gelatinases and are constituents of the heart. MMP-2 is considered a biomarker of patients with HF with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF). The role of MMP-2 in the development of cardiac injury and dysfunction has clearly been demonstrated in animal models of cardiac ischemia, transgenic models that overexpress MMP-2, and knockout models for this protease. New research to minimize cardiac structural and functional alterations using non-selective and selective inhibitors for MMP-2 demonstrates that this protease could be used as a possible pharmacological target in the treatment of HF.
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Affiliation(s)
- Pricila Rodrigues Gonçalves
- Cardiovascular System Pharmacology and Toxicology Laboratory, Institute of Biological Sciences, Federal University of Pará, Belém 66075-110, PA, Brazil; (P.R.G.); (L.D.N.); (K.E.R.)
| | - Lisandra Duarte Nascimento
- Cardiovascular System Pharmacology and Toxicology Laboratory, Institute of Biological Sciences, Federal University of Pará, Belém 66075-110, PA, Brazil; (P.R.G.); (L.D.N.); (K.E.R.)
| | - Raquel Fernanda Gerlach
- Department of Basic and Oral Biology, Faculty of Dentistry of Ribeirao Preto, University of Sao Paulo (FORP/USP), Ribeirao Preto 14040-904, SP, Brazil;
| | - Keuri Eleutério Rodrigues
- Cardiovascular System Pharmacology and Toxicology Laboratory, Institute of Biological Sciences, Federal University of Pará, Belém 66075-110, PA, Brazil; (P.R.G.); (L.D.N.); (K.E.R.)
| | - Alejandro Ferraz Prado
- Cardiovascular System Pharmacology and Toxicology Laboratory, Institute of Biological Sciences, Federal University of Pará, Belém 66075-110, PA, Brazil; (P.R.G.); (L.D.N.); (K.E.R.)
- Correspondence:
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Liu Q, Ji G, Chu Y, Hao T, Qian M, Zhao Q. Enzyme-responsive hybrid prodrug of nitric oxide and hydrogen sulfide for heart failure therapy. Chem Commun (Camb) 2022; 58:7396-7399. [PMID: 35686984 DOI: 10.1039/d2cc02267b] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A hybrid prodrug was synthesized to realize the combined delivery of nitric oxide and hydrogen sulfide. The NO-H2S donor can release nitric oxide and hydrogen sulfide step by step in response to the endogenous enzymes β-galactosidase and carbonic anhydrase, providing potent therapeutic efficacy for heart failure post- myocardial infarction.
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Affiliation(s)
- Qi Liu
- State key Laboratory of Medicinal Chemical Biology, Haihe Laboratory of Sustainable Chemical Transformations, Key Laboratory of Bioactive Materials (Ministry of Education), Frontiers Science Center for Cell Responses, College of Life Sciences, Nankai University, Tianjin 300071, China.
| | - Guangbo Ji
- State key Laboratory of Medicinal Chemical Biology, Haihe Laboratory of Sustainable Chemical Transformations, Key Laboratory of Bioactive Materials (Ministry of Education), Frontiers Science Center for Cell Responses, College of Life Sciences, Nankai University, Tianjin 300071, China.
| | - Yushu Chu
- State key Laboratory of Medicinal Chemical Biology, Haihe Laboratory of Sustainable Chemical Transformations, Key Laboratory of Bioactive Materials (Ministry of Education), Frontiers Science Center for Cell Responses, College of Life Sciences, Nankai University, Tianjin 300071, China.
| | - Tian Hao
- State key Laboratory of Medicinal Chemical Biology, Haihe Laboratory of Sustainable Chemical Transformations, Key Laboratory of Bioactive Materials (Ministry of Education), Frontiers Science Center for Cell Responses, College of Life Sciences, Nankai University, Tianjin 300071, China.
| | - Meng Qian
- State key Laboratory of Medicinal Chemical Biology, Haihe Laboratory of Sustainable Chemical Transformations, Key Laboratory of Bioactive Materials (Ministry of Education), Frontiers Science Center for Cell Responses, College of Life Sciences, Nankai University, Tianjin 300071, China.
| | - Qiang Zhao
- State key Laboratory of Medicinal Chemical Biology, Haihe Laboratory of Sustainable Chemical Transformations, Key Laboratory of Bioactive Materials (Ministry of Education), Frontiers Science Center for Cell Responses, College of Life Sciences, Nankai University, Tianjin 300071, China.
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Zhang H, Xue Y, Pan T, Zhu X, Chong H, Xu C, Fan F, Cao H, Zhang B, Pan J, Zhou Q, Yang G, Wang J, Wang DJ. Epicardial injection of allogeneic human-induced-pluripotent stem cell-derived cardiomyocytes in patients with advanced heart failure: protocol for a phase I/IIa dose-escalation clinical trial. BMJ Open 2022; 12:e056264. [PMID: 35523485 PMCID: PMC9083430 DOI: 10.1136/bmjopen-2021-056264] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Heart failure (HF) is a growing global public health burden. However, due to the very limited regenerative capacity of mature cardiomyocytes in the adult mammalian heart, conventional treatments can only improve the symptoms of HF but fail to restore cardiac function. Heart transplantation is limited by a severe shortage of donors. Cell-based transplantation for the treatment of HF has become a promising strategy. Human-induced-pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) have been tested in animal models to assess safety and efficacy. This study aims at evaluating the safety and efficacy of epicardial injection of hiPSC-CMs in patients with advanced HF during coronary artery bypass grafting (CABG) surgery. METHODS This study is a dose-escalation, placebo-controlled, single-centre phase I/IIa clinical trial. Dose escalation will be guided by a modified 3+3 design for three doses (1×108, 2×108 and 4×108 cells, sequentially). Patients with advanced heart failure will be enrolled and randomly allocated to receive epicardial injection of hiPSC-CMs during CABG surgery or CABG surgery alone, followed by a 12-month follow-up investigation. The primary endpoint is to assess the safety of hiPSC-CMs transplantation, including haemodynamic compromised sustained ventricular arrhythmias and newly formed tumours during 6 months postoperatively. The secondary endpoint is to evaluate the efficacy of epicardial injection of hiPSC-CMs and CABG surgery combination by comparison with CABG surgery alone. ETHICS AND DISSEMINATION The study protocol has been approved by the Institutional Ethical Committee of Nanjing Drum Tower Hospital (No. SC202000102) and approved by National Health Commission of the PRC (MR-32-21-014649). Findings will be disseminated to the academic community through peer-reviewed publications and presentation at national and international meetings. TRIAL REGISTRATION NUMBER NCT03763136.
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Affiliation(s)
- He Zhang
- Department of Cardiothoracic Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, Beijing, China
| | - Yunxing Xue
- Department of Cardiothoracic Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Tuo Pan
- Department of Cardiothoracic Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, Beijing, China
| | - Xiyu Zhu
- Department of Cardiothoracic Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Hoshun Chong
- Department of Cardiothoracic Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Can Xu
- Department of Cardiothoracic Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Fudong Fan
- Department of Cardiothoracic Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Hailong Cao
- Department of Cardiothoracic Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Bomin Zhang
- Department of Cardiothoracic Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Jun Pan
- Department of Cardiothoracic Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Qing Zhou
- Department of Cardiothoracic Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Gang Yang
- HELP Therapeutics, Nanjing, Jiangsu, China
| | | | - Dong-Jin Wang
- Department of Cardiothoracic Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, Beijing, China
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Li Y, Li X, Chen X, Sun X, Liu X, Wang G, Liu Y, Cui L, Liu T, Wang W, Wang Y, Li C. Qishen Granule (QSG) Inhibits Monocytes Released From the Spleen and Protect Myocardial Function via the TLR4-MyD88-NF-κB p65 Pathway in Heart Failure Mice. Front Pharmacol 2022; 13:850187. [PMID: 35370707 PMCID: PMC8964526 DOI: 10.3389/fphar.2022.850187] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/02/2022] [Indexed: 12/12/2022] Open
Abstract
Preliminary clinical and basic researches have proved that Qishen granule (QSG) is an effective prescription for treating heart failure (HF) in China, with a characteristic of regulating the ratio of M1/M2 macrophage in the myocardium. However, the regulative mechanism of monocytes targeting the cardio-splenic axis has not been fully elucidated. This study aimed to investigate the effects and mechanism of QSG inhibiting the release of splenic monocytes and the recruitment of myocardial tissue both in vivo and in vitro. Experiments in mice with acute myocardial infarction (AMI)-induced HF demonstrated that QSG could exert anti-inflammatory effects by inhibiting splenic monocytes release and phenotypic changes. Moreover, in vitro experiments indicated QSG could inhibit LPS-stimulated macrophage-conditioned medium (CM)-induced H9C2 cardiomyocyte injury by upregulating the key proteins in TLR4-MyD88-NF-κB p65 pathway. In addition, knockdown or overexpression of TLR4 in H9C2 cells further confirmed that QSG could attenuate inflammatory injury in cardiomyocytes via the TLR4-MyD88-NF-κB p65 pathway. Overall, these data suggested that QSG could improve cardiac function and reduce the inflammatory response in AMI-induced HF by inhibiting splenic monocytes release, and protecting myocardial function via the TLR4-MyD88-NF-κB pathway in heart failure mice.
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Affiliation(s)
- Yanqin Li
- College of Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Xuan Li
- College of Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Xu Chen
- College of Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaoqian Sun
- College of Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Xiangning Liu
- College of Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Gang Wang
- College of Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Yizhou Liu
- College of Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Lingwen Cui
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Tianhua Liu
- College of Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Wei Wang
- College of Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.,Beijing Key Laboratory of TCM Syndrome and Formula, Beijing University of Chinese Medicine, Beijing, China
| | - Yong Wang
- College of Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.,School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China.,Beijing Key Laboratory of TCM Syndrome and Formula, Beijing University of Chinese Medicine, Beijing, China
| | - Chun Li
- Modern Research Center for Traditional Chinese Medicine (TCM), Beijing University of Chinese Medicine, Beijing, China.,Beijing Key Laboratory of TCM Syndrome and Formula, Beijing University of Chinese Medicine, Beijing, China
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Abstract
Advanced heart failure (HF) is a progressive disease characterized by recurrent hospitalizations and high risk of mortality. Indeed, outcomes in late stages of HF approximate those seen in patients with various aggressive malignancies. Clinical trials assessing beneficial outcomes of new treatments in patients with cancer have used innovative approaches to measure impact on total disease burden or surrogates to assess treatment efficacy. Although most cardiovascular outcomes trials continue to use time-to-first event analyses to assess the primary efficacy end point, such analyses do not adequately reflect the impact of new treatments on the totality of the chronic disease burden. Consequently, patient enrichment and other strategies for ongoing clinical trial design, as well as new statistical methodologies, are important considerations, particularly when studying a population with advanced chronic HF. The DREAM-HF trial (Double-Blind Randomized Assessment of Clinical Events With Allogeneic Mesenchymal Precursor Cells in Advanced Heart Failure) is an ongoing, randomized, sham-controlled phase 3 study of the efficacy and safety of mesenchymal precursor cells as immunotherapy in patients with advanced chronic HF with reduced ejection fraction. Mesenchymal precursor cells have a unique multimodal mechanism of action that is believed to result in polarization of proinflammatory type 1 macrophages in the heart to an anti-inflammatory type 2 macrophage state, inhibition of maladaptive adverse left ventricular remodeling, reversal of cardiac and peripheral endothelial dysfunction, and recovery of deranged vasculature. The objective of DREAM-HF is to confirm earlier phase 2 results and evaluate whether mesenchymal precursor cells will reduce the rate of nonfatal recurrent HF-related major adverse cardiac events while delaying or preventing progression of HF to terminal cardiac events. DREAM-HF is an example of an ongoing contemporary events-driven cardiovascular cell-based immunotherapy study that has utilized the concepts of baseline disease enrichment, prognostic enrichment, and predictive enrichment to improve its efficiency by using accumulating data from within as well as external to the trial. Adaptive enrichment designs and strategies are important components of a rational approach to achieve clinical research objectives in shorter clinical trial timelines and with increased cost-effectiveness without compromising ethical standards or the overall statistical integrity of the study. The DREAM-HF trial also presents an alternative approach to traditional composite time-to-first event primary efficacy end points. Statistical methodologies such as the joint frailty model provide opportunities to expand the scope of events-driven HF with reduced ejection fraction clinical trials to utilize time to recurrent nonfatal HF-related major adverse cardiac events as the primary efficacy end point without compromising the integrity of the statistical analyses for terminal cardiac events. In advanced chronic HF with reduced ejection fraction studies, the joint frailty model is utilized to reflect characteristics of the high-risk patient population with important unmet therapeutic needs. In some cases, use of the joint frailty model may substantially reduce sample size requirements. In addition, using an end point that is acceptable to the Food and Drug Administration and the European Medicines Agency, such as recurrent nonfatal HF-related major adverse cardiac events, enables generation of clinically relevant pharmacoeconomic data while providing comprehensive views of the patient's overall cardiovascular disease burden. The major goal of this review is to provide lessons learned from the ongoing DREAM-HF trial that relate to biologic plausibility and flexible clinical trial design and are potentially applicable to other development programs of innovative therapies for patients with advanced cardiovascular disease. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02032004.
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Affiliation(s)
| | | | - Barry Greenberg
- University of California, San Diego School of Medicine, La Jolla (B.G.)
- Advanced Heart Failure Treatment Program, Sulpizio Cardiovascular Center, University of California, San Diego Healthcare System, La Jolla (B.G.)
| | - Emerson C. Perin
- Stem Cell Center and Adult Cardiology, Texas Heart Institute, Houston (E.C.P.)
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