1
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Lei CL, Whittaker DG, Mirams GR. The impact of uncertainty in hERG binding mechanism on in silico predictions of drug-induced proarrhythmic risk. Br J Pharmacol 2024; 181:987-1004. [PMID: 37740435 DOI: 10.1111/bph.16250] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND AND PURPOSE Drug-induced reduction of the rapid delayed rectifier potassium current carried by the human Ether-à-go-go-Related Gene (hERG) channel is associated with increased risk of arrhythmias. Recent updates to drug safety regulatory guidelines attempt to capture each drug's hERG binding mechanism by combining in vitro assays with in silico simulations. In this study, we investigate the impact on in silico proarrhythmic risk predictions due to uncertainty in the hERG binding mechanism and physiological hERG current model. EXPERIMENTAL APPROACH Possible pharmacological binding models were designed for the hERG channel to account for known and postulated small molecule binding mechanisms. After selecting a subset of plausible binding models for each compound through calibration to available voltage-clamp electrophysiology data, we assessed their effects, and the effects of different physiological models, on proarrhythmic risk predictions. KEY RESULTS For some compounds, multiple binding mechanisms can explain the same data produced under the safety testing guidelines, which results in different inferred binding rates. This can result in substantial uncertainty in the predicted torsade risk, which often spans more than one risk category. By comparison, we found that the effect of a different hERG physiological current model on risk classification was subtle. CONCLUSION AND IMPLICATIONS The approach developed in this study assesses the impact of uncertainty in hERG binding mechanisms on predictions of drug-induced proarrhythmic risk. For some compounds, these results imply the need for additional binding data to decrease uncertainty in safety-critical applications.
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Affiliation(s)
- Chon Lok Lei
- Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau, China
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Macau, Macau, China
| | - Dominic G Whittaker
- Centre for Mathematical Medicine & Biology, School of Mathematical Sciences, University of Nottingham, Nottingham, UK
| | - Gary R Mirams
- Centre for Mathematical Medicine & Biology, School of Mathematical Sciences, University of Nottingham, Nottingham, UK
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2
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Wiley AM, Yang J, Madhani R, Nath A, Totah RA. Investigating the association between CYP2J2 inhibitors and QT prolongation: a literature review. Drug Metab Rev 2024; 56:145-163. [PMID: 38478383 DOI: 10.1080/03602532.2024.2329928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/06/2024] [Indexed: 03/21/2024]
Abstract
Drug withdrawal post-marketing due to cardiotoxicity is a major concern for drug developers, regulatory agencies, and patients. One common mechanism of cardiotoxicity is through inhibition of cardiac ion channels, leading to prolongation of the QT interval and sometimes fatal arrythmias. Recently, oxylipin signaling compounds have been shown to bind to and alter ion channel function, and disruption in their cardiac levels may contribute to QT prolongation. Cytochrome P450 2J2 (CYP2J2) is the predominant CYP isoform expressed in cardiomyocytes, where it oxidizes arachidonic acid to cardioprotective epoxyeicosatrienoic acids (EETs). In addition to roles in vasodilation and angiogenesis, EETs bind to and activate various ion channels. CYP2J2 inhibition can lower EET levels and decrease their ability to preserve cardiac rhythm. In this review, we investigated the ability of known CYP inhibitors to cause QT prolongation using Certara's Drug Interaction Database. We discovered that among the multiple CYP isozymes, CYP2J2 inhibitors were more likely to also be QT-prolonging drugs (by approximately 2-fold). We explored potential binding interactions between these inhibitors and CYP2J2 using molecular docking and identified four amino acid residues (Phe61, Ala223, Asn231, and Leu402) predicted to interact with QT-prolonging drugs. The four residues are located near the opening of egress channel 2, highlighting the potential importance of this channel in CYP2J2 binding and inhibition. These findings suggest that if a drug inhibits CYP2J2 and interacts with one of these four residues, then it may have a higher risk of QT prolongation and more preclinical studies are warranted to assess cardiovascular safety.
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Affiliation(s)
- Alexandra M Wiley
- Department of Medicinal Chemistry, University of WA School of Pharmacy, Seattle, WA, USA
| | - Jade Yang
- Department of Medicinal Chemistry, University of WA School of Pharmacy, Seattle, WA, USA
| | - Rivcka Madhani
- Department of Medicinal Chemistry, University of WA School of Pharmacy, Seattle, WA, USA
| | - Abhinav Nath
- Department of Medicinal Chemistry, University of WA School of Pharmacy, Seattle, WA, USA
| | - Rheem A Totah
- Department of Medicinal Chemistry, University of WA School of Pharmacy, Seattle, WA, USA
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3
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Farm HJ, Clerx M, Cooper F, Polonchuk L, Wang K, Gavaghan DJ, Lei CL. Importance of modelling hERG binding in predicting drug-induced action potential prolongations for drug safety assessment. Front Pharmacol 2023; 14:1110555. [PMID: 37021055 PMCID: PMC10067903 DOI: 10.3389/fphar.2023.1110555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/22/2023] [Indexed: 03/30/2023] Open
Abstract
Reduction of the rapid delayed rectifier potassium current (IKr) via drug binding to the human Ether-à-go-go-Related Gene (hERG) channel is a well recognised mechanism that can contribute to an increased risk of Torsades de Pointes. Mathematical models have been created to replicate the effects of channel blockers, such as reducing the ionic conductance of the channel. Here, we study the impact of including state-dependent drug binding in a mathematical model of hERG when translating hERG inhibition to action potential changes. We show that the difference in action potential predictions when modelling drug binding of hERG using a state-dependent model versus a conductance scaling model depends not only on the properties of the drug and whether the experiment achieves steady state, but also on the experimental protocols. Furthermore, through exploring the model parameter space, we demonstrate that the state-dependent model and the conductance scaling model generally predict different action potential prolongations and are not interchangeable, while at high binding and unbinding rates, the conductance scaling model tends to predict shorter action potential prolongations. Finally, we observe that the difference in simulated action potentials between the models is determined by the binding and unbinding rate, rather than the trapping mechanism. This study demonstrates the importance of modelling drug binding and highlights the need for improved understanding of drug trapping which can have implications for the uses in drug safety assessment.
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Affiliation(s)
- Hui Jia Farm
- Department of Computer Science, University of Oxford, Oxford, United Kingdom
| | - Michael Clerx
- Centre for Mathematical Medicine and Biology, School of Mathematical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Fergus Cooper
- Doctoral Training Centre, University of Oxford, Oxford, United Kingdom
| | - Liudmila Polonchuk
- Roche Pharma Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Ken Wang
- Roche Pharma Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - David J. Gavaghan
- Department of Computer Science, University of Oxford, Oxford, United Kingdom
- Doctoral Training Centre, University of Oxford, Oxford, United Kingdom
- *Correspondence: David J. Gavaghan, ; Chon Lok Lei,
| | - Chon Lok Lei
- Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau, China
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Macau, Macau, China
- *Correspondence: David J. Gavaghan, ; Chon Lok Lei,
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4
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Serrano R, Feyen DAM, Bruyneel AAN, Hnatiuk AP, Vu MM, Amatya PL, Perea-Gil I, Prado M, Seeger T, Wu JC, Karakikes I, Mercola M. A deep learning platform to assess drug proarrhythmia risk. Cell Stem Cell 2023; 30:86-95.e4. [PMID: 36563695 PMCID: PMC9924077 DOI: 10.1016/j.stem.2022.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/25/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
Drug safety initiatives have endorsed human iPSC-derived cardiomyocytes (hiPSC-CMs) as an in vitro model for predicting drug-induced cardiac arrhythmia. However, the extent to which human-defined features of in vitro arrhythmia predict actual clinical risk has been much debated. Here, we trained a convolutional neural network classifier (CNN) to learn features of in vitro action potential recordings of hiPSC-CMs that are associated with lethal Torsade de Pointes arrhythmia. The CNN classifier accurately predicted the risk of drug-induced arrhythmia in people. The risk profile of the test drugs was similar across hiPSC-CMs derived from different healthy donors. In contrast, pathogenic mutations that cause arrhythmogenic cardiomyopathies in patients significantly increased the proarrhythmic propensity to certain intermediate and high-risk drugs in the hiPSC-CMs. Thus, deep learning can identify in vitro arrhythmic features that correlate with clinical arrhythmia and discern the influence of patient genetics on the risk of drug-induced arrhythmia.
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Affiliation(s)
- Ricardo Serrano
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA 94305, USA; Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA 94305, USA
| | - Dries A M Feyen
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA 94305, USA; Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA 94305, USA
| | - Arne A N Bruyneel
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA 94305, USA; Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA 94305, USA
| | - Anna P Hnatiuk
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA 94305, USA; Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA 94305, USA
| | - Michelle M Vu
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA 94305, USA; Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA 94305, USA
| | - Prashila L Amatya
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA 94305, USA; Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA 94305, USA
| | - Isaac Perea-Gil
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA 94305, USA; Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA
| | - Maricela Prado
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA 94305, USA; Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA
| | - Timon Seeger
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA 94305, USA; Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA 94305, USA
| | - Joseph C Wu
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA 94305, USA; Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA 94305, USA
| | - Ioannis Karakikes
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA 94305, USA; Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA
| | - Mark Mercola
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA 94305, USA; Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA 94305, USA.
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5
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Hage A, de Vries M, Leffler A, Stoetzer C. Local Anesthetic Like Inhibition of the Cardiac Na+ Channel Nav1.5 by Chloroquine and Hydroxychloroquine. J Exp Pharmacol 2022; 14:353-365. [DOI: 10.2147/jep.s375349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 10/16/2022] [Indexed: 11/09/2022] Open
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Kim SH, Lee JG, Ju HM, Choi S, Yang H, Koo BN. Propofol prevents further prolongation of QT interval during liver transplantation. Sci Rep 2022; 12:4636. [PMID: 35301381 PMCID: PMC8931121 DOI: 10.1038/s41598-022-08592-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/28/2022] [Indexed: 11/21/2022] Open
Abstract
Here, we aimed to compare the effects of two anesthetic methods (desflurane inhalation anesthesia vs. propofol-based total intravenous anesthesia (TIVA)] on corrected QT interval (QTc) values during living donor liver transplantation. Altogether, 120 patients who underwent living donor liver transplantation were randomized to either the desflurane or TIVA group. The primary outcome was intraoperative QTc change. Other electrocardiogram, hemodynamic findings and postoperative outcomes were examined as secondary outcomes. QTc values were prolonged intraoperatively in both groups; however, the change was smaller in the TIVA group than in the desflurane group (PGroup × Time < 0.001). More patients had QTc values of > 500 ms in the desflurane group than in the TIVA group (63.3% vs. 28.3%, P < 0.001). In patients with preoperative QTc prolongation, QTc was further prolonged in the desflurane group, but not in the TIVA group (PGroup × Time < 0.001). Intraoperative norepinephrine and vasopressin use were higher in the desflurane group than in the TIVA group. Propofol-based TIVA may reduce QTc prolongation during living donor liver transplantation compared to that observed with desflurane inhalational anesthesia, particularly in patients with preoperative QTc prolongation. Additionally, patients managed with propofol-based TIVA required less vasopressor during the procedure as compared with those managed with desflurane inhalational anesthesia.
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Affiliation(s)
- Seung Hyun Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyang Mi Ju
- Department of Anesthesiology and Pain Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - SuYoun Choi
- Department of Anesthesiology and Pain Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyukjin Yang
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea.
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7
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QT interval measurement in ventricular pacing: Implications for assessment of drug effects and pro-arrhythmia risk. J Electrocardiol 2021; 70:13-18. [PMID: 34826635 DOI: 10.1016/j.jelectrocard.2021.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/08/2021] [Accepted: 11/12/2021] [Indexed: 11/22/2022]
Abstract
QT interval prolongation is a known risk factor for development of malignant ventricular arrhythmias. Measurement of the QT interval is difficult in the setting of ventricular pacing (VP), which can prolong depolarization and increase the QT interval, overestimating repolarization time. VP and cardiac resynchronization therapies have become commonplace in modern cardiac care and may contribute to repolarization heterogeneity and subsequent increased risk for ventricular arrhythmias including Torsades de Pointes. It is imperative for the clinician caring for acutely ill cardiac patients to understand the relationship between QT interval prolongation, both drug-induced and pacing-induced, and repolarization changes with subsequent ventricular arrhythmia risk. In this review, we discuss the components of QT interval assessment for arrhythmogenic risk including arrhythmogenic QT prolongation, methods for adjusting the QT interval to identify repolarization changes, methods to adjust for heart rate, and propose a framework for medication management to assess for drug-induced long QT syndrome in patients with VP.
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8
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Putnikovic M, Ward M, Jordan Z. Use of ECG monitoring for adult patients taking high-risk QT interval-prolonging drugs in clinical practice: a systematic review protocol. JBI Evid Synth 2021; 19:3113-3120. [PMID: 34054036 DOI: 10.11124/jbies-20-00473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The objective of this review is to determine the rates of electrocardiogram use in adult patients taking high-risk QT interval-prolonging drugs in clinical settings. This review will determine the extent of ECG monitoring being used to mitigate the risk of drug-induced QT prolongation. INTRODUCTION High-risk QT interval-prolonging drugs pose a well-established risk of cardiac arrhythmia, including torsades de pointes, among other serious long QT syndromes, which can be fatal. Detection and mitigation of QT prolongation involves use of electrocardiogram monitoring. This systematic review will present evidence for uptake of electrocardiogram monitoring in clinical practice to support the quality use of high-risk QT interval-prolonging drugs. INCLUSION CRITERIA Quantitative studies, published from 2004 that determine the rate of electrocardiogram monitoring before and during use of high-risk QT interval-prolonging drugs in adults 18 years or older, either in community or hospital settings, will be eligible for inclusion. METHODS CINAHL, Cochrane Library, Embase, and PubMed will be searched to identify published studies. EThOS, OpenGrey, and ProQuest Dissertations and Theses will be searched to identify unpublished studies. Conference abstracts will be excluded. There will be no restriction on country or language. Two reviewers will independently screen and select studies, assess methodological quality, and extract data. The JBI approach to systematic reviews of prevalence and incidence will be followed. Meta-analysis will be performed, if possible, and the Grading of Recommendations Assessment Development and Evaluation (GRADE) Summary of Findings presented.
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Affiliation(s)
- Marijana Putnikovic
- JBI, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia.,The Centre for Evidence-based Practice South Australia (CEPSA): A JBI Centre of Excellence, Adelaide, SA, Australia
| | - Michael Ward
- Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Zoe Jordan
- JBI, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia.,The Centre for Evidence-based Practice South Australia (CEPSA): A JBI Centre of Excellence, Adelaide, SA, Australia
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9
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Eroglu TE, Blom MT, Souverein PC, de Boer A, Tan HL. Multiple categories of non-cardiac QT-prolonging drugs are associated with increased risk of out-of-hospital cardiac arrest: real-world data from a population-based study. Europace 2021; 24:630-638. [PMID: 34661653 PMCID: PMC8982417 DOI: 10.1093/europace/euab251] [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: 05/26/2021] [Accepted: 10/01/2021] [Indexed: 11/16/2022] Open
Abstract
Aim Drugs causing QT-prolongation as off-target effect [non-cardiac QT-prolonging drugs (QT-drugs)] increase the risk of out-of-hospital cardiac arrest (OHCA). Such drugs are categorized in multiple clinically widely used CredibleMeds.org lists. Category 1 (‘known risk of Torsade de Pointes’) and category 2 (‘possible risk of Torsade de Pointes’) are of particular clinical relevance. However, a category-stratified analysis of OHCA-risk is presently unavailable. Methods and results We conducted a case–control study with OHCA-cases from presumed cardiac causes included from the ARREST registry in the Netherlands (2009–2018) that was specifically designed to study OHCA, and age/sex/OHCA-date matched non-OHCA-controls. Adjusted odds ratios for OHCA (ORadj) of QT-drugs from categories 1 or 2 were calculated, using conditional logistic regression. Stratified analysis was performed according to sex, age, and presence of cardiovascular drugs (proxy for cardiovascular disease). We included 5473 OHCA-cases (68.8 years, 69.9% men) and matched them to 20 866 non-OHCA-controls. Compared with no use of non-cardiac QT-drugs, drugs of both categories were associated with increased OHCA-risk, but seemingly weaker for category 2 {category 1: case 3.2%, control 1.4%, ORadj 1.7 [95% confidence interval (CI): 1.3–2.1]}; [category 2: case 7.3%, control 4.0%, ORadj 1.4 (95% CI: 1.2–1.6)]. The increased risk occurred in men and women, at all ages (highest in patients aged ≤50 years), and both in the presence or absence of cardiovascular drug use. Conclusion Both category 1 and category 2 QT-drugs are associated with increased OHCA-risk in both sexes, at all ages, and in patients taking or not taking cardiovascular drugs.
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Affiliation(s)
- Talip E Eroglu
- Department of Cardiology, Heart Center, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
| | - Marieke T Blom
- Department of Cardiology, Heart Center, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Hanno L Tan
- Department of Cardiology, Heart Center, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
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10
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Post AD, Buchan S, John M, Safavi-Naeini P, Cosgriff-Hernández E, Razavi M. Reconstituting electrical conduction in soft tissue: the path to replace the ablationist. Europace 2021; 23:1892-1902. [PMID: 34477862 DOI: 10.1093/europace/euab187] [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: 03/23/2021] [Accepted: 07/08/2021] [Indexed: 11/13/2022] Open
Abstract
Cardiac arrhythmias are a leading cause of morbidity and mortality in the developed world. A common mechanism underlying many of these arrhythmias is re-entry, which may occur when native conduction pathways are disrupted, often by myocardial infarction. Presently, re-entrant arrhythmias are most commonly treated with antiarrhythmic drugs and myocardial ablation, although both treatment methods are associated with adverse side effects and limited efficacy. In recent years, significant advancements in the field of biomaterials science have spurred increased interest in the development of novel therapies that enable restoration of native conduction in damaged or diseased myocardium. In this review, we assess the current landscape of materials-based approaches to eliminating re-entrant arrhythmias. These approaches potentially pave the way for the eventual replacement of myocardial ablation as a preferred therapy for such pathologies.
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Affiliation(s)
- Allison D Post
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX 77030, USA
| | - Skylar Buchan
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX 77030, USA
| | - Mathews John
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX 77030, USA
| | - Payam Safavi-Naeini
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX 77030, USA
| | | | - Mehdi Razavi
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX 77030, USA.,Department of Cardiology, Baylor College of Medicine, Houston, TX, USA
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11
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Liu X, Duan X, Fan H, Wang H, Jiang X, Fang Y, Tang Q, Xiao J, Li Q. 8-hydroxypinoresinol-4-O-β-D-glucoside from Valeriana officinalis L. Is a Novel Kv1.5 Channel Blocker. JOURNAL OF ETHNOPHARMACOLOGY 2021; 276:114168. [PMID: 33932511 DOI: 10.1016/j.jep.2021.114168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 06/12/2023]
Abstract
ETHNOPHARMACOLOGY RELEVANCE In folkloric medicine of many cultures, one of the medical uses of Valeriana officinalis Linn is to treat heart-related disease. Recently, it was shown that the ethanol extracts from V. officinalis could effectively prevent auricular fibrillation, and 8-hydroxypinoresinol-4-O-β-D-glucoside (HPG) from the extracts is one of the two active compounds showing antiarrhythmia activities. AIM OF THE STUDY The human Kv1.5 channel (hKv1.5) has potential antiarrhythmia activities, and this study arms at investigating the current blocking effects of HPG on hKv1.5 channel. MATERIAL AND METHODS HPG was obtained from V. officinalis extracts, and hKv1.5 channels were expressed in HEK 293 cells. HPG was perfused while recording the current through hKv1.5 channels. Patch-clamp recording techniques were used to study the effects of HPG at various concentrations (10 μM, 30 μM, and 50 μM) on hKv1.5 channels. RESULTS The present study demonstrated that HPG inhibited hKv1.5 channel current in a concentration-dependent manner; the higher the concentration, the greater is the inhibition at each depolarization potential. During washout, the channels did not full recover indicating that the un-coupling between HPG and hKv1.5 channels is a slow process. CONCLUSION HPG may be an effective and safe active ingredient for AF having translational potential.
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Affiliation(s)
- Xingxing Liu
- Department of Integrated Traditional Chinese and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Liberty Rd., Wuhan, Hubei, 430022, China
| | - Xueyun Duan
- Pharmaceutical Department, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, 430061, Hubei Province, China
| | - Heng Fan
- Department of Integrated Traditional Chinese and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Liberty Rd., Wuhan, Hubei, 430022, China
| | - Hongfei Wang
- Department of Cardiac Surgery, Department of Integrated Traditional Chinese Medicine and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Liberty Rd., Wuhan, Hubei, 430022, China
| | - Xionggang Jiang
- Department of Cardiac Surgery, Department of Integrated Traditional Chinese Medicine and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Liberty Rd., Wuhan, Hubei, 430022, China
| | - Ying Fang
- Hubei University of Chinese Medicine, 16 Huangjiahu W Rd, Hongshan, Wuhan, Hubei, 430065, China
| | - Qing Tang
- Department of Integrated Traditional Chinese and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Liberty Rd., Wuhan, Hubei, 430022, China
| | - Jun Xiao
- The Macrohard Institute of Health, 231 North Ave, Battle Creek, MI, 49017, USA.
| | - Qian Li
- The Macrohard Institute of Health, 231 North Ave, Battle Creek, MI, 49017, USA; The American Academy of Tradition Chinese Medicine Inc., 1925 W County Rd B2, Roseville, MN, 55113, USA.
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12
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Ellermann C, Wolfes J, Eckardt L, Frommeyer G. Role of the rabbit whole-heart model for electrophysiologic safety pharmacology of non-cardiovascular drugs. Europace 2021; 23:828-836. [PMID: 33200170 DOI: 10.1093/europace/euaa288] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/27/2020] [Indexed: 11/13/2022] Open
Abstract
Plenty of non-cardiovascular drugs alter cardiac electrophysiology and may ultimately lead to life-threatening arrhythmias. In clinical practice, measuring the QT interval as a marker for the repolarization period is the most common tool to assess the electrophysiologic safety of drugs. However, the sole measurement of the QT interval may be insufficient to determine the proarrhythmic risk of non-cardiovascular agents. Several other markers are considered in pre-clinical safety testing to determine potential harm on cardiac electrophysiology. Besides measuring typical electrophysiologic parameters such as repolarization duration, whole-heart models allow the determination of potential predictors for proarrhythmia. Spatial and temporal heterogeneity as well as changes of shape of the action potential can be easily assessed. In addition, provocation manoeuvers (either by electrolyte imbalances or programmed pacing protocols) may induce sustained arrhythmias and thereby determine ventricular vulnerability to arrhythmias. Compared with the human heart, the rabbit heart possesses a similar distribution of ion currents that govern cardiac repolarization, resulting in a rectangular action potential configuration in both species. In addition, similar biophysical properties of rabbit and human cardiac ion channels lead to a comparable pharmacologic response in human and rabbit hearts. Of note, arrhythmia patterns resemble in both species due to the similar effective size of human and rabbit hearts. Thus, the rabbit heart is particularly suitable for testing the electrophysiologic safety of drugs. Several experimental setups have been developed for studying cardiac electrophysiology in rabbits, ranging from single cell to tissue preparations, whole-heart setups, and in vivo models.
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Affiliation(s)
- Christian Ellermann
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, Münster D-48149, Germany
| | - Julian Wolfes
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, Münster D-48149, Germany
| | - Lars Eckardt
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, Münster D-48149, Germany
| | - Gerrit Frommeyer
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, Münster D-48149, Germany
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13
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Környei L, Szabó A, Róth G, Ferenci T, Kardos A. Supraventricular tachycardias in neonates and infants: factors associated with fatal or near-fatal outcome. Eur J Pediatr 2021; 180:2669-2676. [PMID: 34184119 DOI: 10.1007/s00431-021-04159-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/13/2021] [Accepted: 06/10/2021] [Indexed: 11/25/2022]
Abstract
Prognosis of supraventricular tachycardias in neonates and infants is thought to be excellent with rare fatal outcomes. Nevertheless, initial management can be challenging. The aim of this study was to perform a retrospective analysis in neonates/infants with non-pos-toperative supraventricular tachycardias regarding risk factors for clinical outcome and type of antiarrhythmic drug therapy. The data of 157 patients aged < 1 year who presented between 2000 and 2015 with symptomatic tachycardias were retrospectively reviewed. Pharmacological therapy was successful in 151 patients (96%); 1 patient (1%) required catheter ablation and 5 patients (3%) died (1 death linked to hemodynamical reasons after effective arrhythmia control). Serious complications following acute medical therapy occurred in 4 patients of survivors. Patients with complications or death had a lower bodyweight, more frequent intrauterine tachycardia, transplacental therapy, urgent caesarian section, higher PRISM II score, longer period to control tachycardia, more frequent proarrhythmia, and major adverse event-defined as life-threatening event without a documented new arrhythmia-compared to the group without complications. There was no significant difference between the groups regarding prematurity, structural heart disease, and type of tachycardia. Proarrhythmia occurred in 6 cases and was related to intravenous drug use with class IC antiarrhythmics in 3/6 cases, digoxin in 2/6 cases, and amiodarone in 1/6 cases. ECG signs of impending proarrhythmia without new-onset arrhythmia requiring cessation of therapy were detected in 6 patients.Conclusion: Although rare, non-post-operative supraventricular tachycardia in neonates and infants might be a serious disease. Acute intravenous pharmacological treatment to control tachycardia might pose a risk for fatal or near-fatal outcome. Detection of proarrhythmia related to class IC antiarrhythmics in neonates might be especially difficult and requires alertness. What is Known • Prognosis of supraventricular tachycardias in children are thought to be excellent with fatal outcomes being rare. • Mortality is increased in the very young and in those with structural heart disease. What is New • Complicated outcome of non-post-operative supraventricular tachycardias in neonates is associated with lower bodyweight, age, prenatal tachycardia, higher PRISM II score, longer period to control tachycardia, and proarrhythmia. • Detection of class IC proarrhythmic effect is especially difficult in neonates because of their narrow QRS and warrants alertness.
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Affiliation(s)
- László Környei
- Hungarian Pediatric Heart Center, Gottsegen György Hungarian Institute of Cardiology, Haller u. 29, Budapest, 1096, Hungary.
| | - Andrea Szabó
- Hungarian Pediatric Heart Center, Gottsegen György Hungarian Institute of Cardiology, Haller u. 29, Budapest, 1096, Hungary
| | - György Róth
- Hungarian Pediatric Heart Center, Gottsegen György Hungarian Institute of Cardiology, Haller u. 29, Budapest, 1096, Hungary
| | - Tamás Ferenci
- Physiological Controls Research Center, Óbuda University, Budapest, Hungary.,Department of Statistics, Corvinus University of Budapest, Budapest, Hungary
| | - Attila Kardos
- Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
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14
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Campana C, Dariolli R, Boutjdir M, Sobie EA. Inflammation as a Risk Factor in Cardiotoxicity: An Important Consideration for Screening During Drug Development. Front Pharmacol 2021; 12:598549. [PMID: 33953668 PMCID: PMC8091045 DOI: 10.3389/fphar.2021.598549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 03/31/2021] [Indexed: 01/08/2023] Open
Abstract
Numerous commonly prescribed drugs, including antiarrhythmics, antihistamines, and antibiotics, carry a proarrhythmic risk and may induce dangerous arrhythmias, including the potentially fatal Torsades de Pointes. For this reason, cardiotoxicity testing has become essential in drug development and a required step in the approval of any medication for use in humans. Blockade of the hERG K+ channel and the consequent prolongation of the QT interval on the ECG have been considered the gold standard to predict the arrhythmogenic risk of drugs. In recent years, however, preclinical safety pharmacology has begun to adopt a more integrative approach that incorporates mathematical modeling and considers the effects of drugs on multiple ion channels. Despite these advances, early stage drug screening research only evaluates QT prolongation in experimental and computational models that represent healthy individuals. We suggest here that integrating disease modeling with cardiotoxicity testing can improve drug risk stratification by predicting how disease processes and additional comorbidities may influence the risks posed by specific drugs. In particular, chronic systemic inflammation, a condition associated with many diseases, affects heart function and can exacerbate medications’ cardiotoxic effects. We discuss emerging research implicating the role of inflammation in cardiac electrophysiology, and we offer a perspective on how in silico modeling of inflammation may lead to improved evaluation of the proarrhythmic risk of drugs at their early stage of development.
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Affiliation(s)
- Chiara Campana
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Rafael Dariolli
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Mohamed Boutjdir
- Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn, NY, United States.,Department of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn, NY, United States.,Department of Medicine, New York University School of Medicine, New York, NY, United States
| | - Eric A Sobie
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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15
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Fung KW, Baye F, Kapusnik-Uner J, McDonald CJ. Using Medicare Data to Assess the Proarrhythmic Risk of Non-Cardiac Treatment Drugs that Prolong the QT Interval in Older Adults: An Observational Cohort Study. Drugs Real World Outcomes 2021; 8:173-185. [PMID: 33569737 PMCID: PMC7875170 DOI: 10.1007/s40801-021-00230-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Serious cardiac arrhythmias caused by QT-prolonging drugs are difficult to predict based on physiological measurement and pre-approval clinical trials. Post-marketing surveillance and monitoring are important to generate safety data. Objectives To assess whether an observational study using Medicare claims data can detect the arrhythmogenic risk of QT-prolonging drugs. Methods We identified 17 QT-prolonging drugs with known risk of torsades des pointes (TdP) that were not used to treat cardiac arrhythmias. Amoxicillin and four serotonin-norepinephrine reuptake inhibitors (SNRIs) were used as controls. De-identified claims data of 1.2 million Medicare beneficiaries were accessed. Two separate Cox regressions were done for short-term and chronic-use drugs. The primary outcome was a composite of ventricular arrhythmias and/or sudden death, identified by ICD diagnostic codes. We explored the independent effect of each study drug on the outcomes. Other covariates included patient demographics, comorbidities, and known risk factors for drug-induced cardiac arrhythmia. Results We were able to detect increased risk in 14 of 17 study drugs (82.3%), and none of the control drugs. Among the fluoroquinolones, ciprofloxacin was the safest. Azithromycin and clarithromycin were relatively safe compared to erythromycin. Compared to SNRIs, both citalopram and escitalopram had increased risk, more so with escitalopram than citalopram. Comorbidities associated with increased risk included ischemic heart disease, electrolyte imbalance, bradycardia, acute myocardial infarction, heart failure, and chronic kidney and liver disease. Conclusion Medicare data can be utilized for post-marketing surveillance and monitoring of the proarrhythmic risk of QT-prolonging drugs in older adults. Supplementary Information The online version contains supplementary material available at 10.1007/s40801-021-00230-1.
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Affiliation(s)
- Kin Wah Fung
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, U.S. National Institutes of Health, 8600 Rockville Pike, Bethesda, MD, 20894, USA.
| | - Fitsum Baye
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, U.S. National Institutes of Health, 8600 Rockville Pike, Bethesda, MD, 20894, USA
| | - Joan Kapusnik-Uner
- First Databank. Inc., San Francisco, CA, USA.,University of California, San Francisco, CA, USA
| | - Clement J McDonald
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, U.S. National Institutes of Health, 8600 Rockville Pike, Bethesda, MD, 20894, USA
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16
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Xiong GL, Pinkhasov A, Mangal JP, Huang H, Rado J, Gagliardi J, Demoss D, Karol D, Suo S, Lang M, Stern M, Spearman EV, Onate J, Annamalai A, Saliba Z, Heinrich T, Fiedorowicz JG. QTc monitoring in adults with medical and psychiatric comorbidities: Expert consensus from the Association of Medicine and Psychiatry. J Psychosom Res 2020; 135:110138. [PMID: 32442893 DOI: 10.1016/j.jpsychores.2020.110138] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/30/2020] [Accepted: 05/07/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Several psychiatric medications have the potential to prolong the QTc interval and subsequently increase the risk for ventricular arrhythmias such as torsades de pointes (TdP). There is limited guidance for clinicians to balance the risks and benefits of treatments. METHODS After a review of the existing literature, clinical-educators from the Association of Medicine and Psychiatry developed expert consensus guidelines for ECG monitoring of the QTc interval for patients with medical and psychiatric comorbidities who are prescribed medications with the potential to prolong the QTc interval. A risk score was developed based on risk factors for QTc prolongation to guide clinical decision-making. RESULTS A baseline ECG may not be necessary for individuals at low risk for arrythmia. Those individuals with a risk score of two or more should have an ECG prior to the start of a potentially QTc-prolonging medication or be started on a lower risk agent. Antipsychotics are not equivalent in causing QTc prolongation. A consensus-based algorithm is presented for the management of those identified at high (QTc >500 msec), intermediate (males with QTc 450-499 msec or females with QTc > 470-499 msec), or low risk. CONCLUSIONS The proposed algorithm can help clinicians in determining whether ECG monitoring should be considered for a given patient. These guidelines preserve a role for clinical judgment in selection of treatments that balance the risks and benefits, which may be particularly relevant for complex patients with medical and psychiatric comorbidities. Additional studies are needed to determine whether baseline and serial ECG monitoring reduces mortality.
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Affiliation(s)
- Glen L Xiong
- Department of Psychiatry and Behavioral Sciences, University of California at Davis School of Medicine, Sacramento, CA, United States of America.
| | - Aaron Pinkhasov
- Department of Behavioral Health, NYU Winthrop Hospital, Mineola, NY, United States of America
| | - Jed P Mangal
- Department of Behavioral Health, Martin Army Community Hospital, Ft Benning, GA, United States of America
| | - Heather Huang
- Departments of Psychiatry and Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
| | - Jeffrey Rado
- Psychiatry and General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Jane Gagliardi
- Departments of Psychiatry and Behavioral Sciences, and Internal Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Dustin Demoss
- Department of Psychiatry, University of North Texas Health Science Center, United States of America
| | - David Karol
- Department of Psychiatry and Behavioral Neuroscience, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - Shannon Suo
- Department of Psychiatry and Behavioral Sciences, University of California at Davis School of Medicine, Sacramento, CA, United States of America
| | - Michael Lang
- Departments of Psychiatry and Internal Medicine, East Carolina University, Greenville, NC, United States of America
| | - Marsha Stern
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
| | - E Vanessa Spearman
- Departments of Internal Medicine and Psychiatry, Medical College of Georgia at Augusta University Medical Center, Augusta, GA, United States of America
| | - John Onate
- Department of Psychiatry and Behavioral Sciences, University of California at Davis School of Medicine, Sacramento, CA, United States of America
| | - Aniyizhai Annamalai
- Departments of Psychiatry and Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Zeina Saliba
- Department of Psychiatry & Behavioral Sciences and Department of Emergency Medicine, The George Washington University, Washington, D.C, Department of Obstetrics & Gynecology, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Thomas Heinrich
- Departments of Psychiatry and Behavioral Medicine, Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Jess G Fiedorowicz
- Departments of Psychiatry, Epidemiology, and Internal Medicine, University of Iowa, Iowa City, IA, United States of America
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17
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Practical Considerations for Treatment of Relapsed/Refractory FLT3-ITD Acute Myeloid Leukaemia with Quizartinib: Illustrative Case Reports. Clin Drug Investig 2020; 40:227-235. [PMID: 31912423 PMCID: PMC7035240 DOI: 10.1007/s40261-019-00881-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Quizartinib is a tyrosine kinase inhibitor selectively targeting the FMS-like tyrosine kinase 3 (FLT3) receptor that has been developed for the treatment of acute myeloid leukaemia (AML). The Phase 3 QuANTUM-R study investigated the efficacy of quizartinib monotherapy in patients with relapsed/refractory FLT3-ITD mutation-positive AML. The clinical course of four QuANTUM-R participants exemplifies issues specific to quizartinib treatment and is described here. Patient 1 was FLT3-ITD mutation-negative at AML diagnosis, but became FLT3-ITD mutation-positive during treatment that included several lines of chemotherapy and was therefore a suitable candidate for quizartinib. Because of the clonal shifts of AML during treatment, retesting genetic alterations at each relapse or resistance may help to identify candidates for targeted treatment options. Patient 2 developed QTc prolongation during quizartinib treatment, but the QTc interval normalised after dose reduction, allowing the patient to continue treatment and eventually resume the recommended dose. Patient 3 responded to quizartinib and was scheduled for haematopoietic stem cell transplant (HSCT), but developed febrile neutropenia and invasive aspergillosis during conditioning and subsequently died (to avoid drug-drug interactions, no azole antifungal was administered concomitantly). Care is required when selecting concomitant medications, and if there is potential for interactions (e.g. if prophylactic azole antifungals are required) the quizartinib dose should be reduced to minimise the risk of QTc prolongation. Patient 4 was able to undergo HSCT after responding to quizartinib and experienced a durable response after HSCT while on quizartinib maintenance therapy. Together, these cases illustrate the main issues to be addressed when managing patients under quizartinib, allowing for adequate scheduling and tolerability, bridging to HSCT, and durable remission on maintenance therapy in some patients.
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18
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Krisai P, Vlachos K, Ramirez FD, Nakatani Y, Nakashima T, Takagi T, Kamakura T, Surget E, André C, Cheniti G, Welte N, Chauvel R, Tixier R, Duchateau J, Pambrun T, Derval N, Hocini M, Jaïs P, Haïssaguerre M, Sacher F. Evaluation of the QT interval in patients with drug-induced QT prolongation and torsades de pointes. J Cardiovasc Electrophysiol 2020; 31:2696-2701. [PMID: 32700358 DOI: 10.1111/jce.14687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/15/2020] [Accepted: 07/06/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Data on the optimal location of the electrocardiogram (ECG) leads for the diagnosis of drug-induced long QT syndrome (diLQTS) with torsades de pointes (TdP) are lacking. METHODS We systematically reviewed the literature for the ECGs of patients with diLQTS and subsequent TdP. We assessed T wave morphology in each lead and measured the longest QT interval in the limb and chest leads in a standardized fashion. RESULTS Of 84 patients, 61.9% were female and the mean age was 58.8 years. QTc was significantly longer in chest versus limb leads (mean (SD) 671 (102) vs. 655 (97) ms, p = .02). Using only limb leads for QT interpretation, 18 (21.4%) ECGs were noninterpretable: 10 (11.9%) due to too flat T waves, 7 (8.3%) due to frequent, early PVCs and 1 (1.2%) due to too low ECG recording quality. In the chest leads, ECGs were noninterpretable in nine (10.7%) patients: six (7.1%) due to frequent, early PVCs, one (1.2%) due to insufficient ECG quality, two (2.4%) due to missing chest leads but none due to too flat T waves. The most common T wave morphologies in the limb leads were flat (51.0%), broad (14.3%), and late peaking (12.6%) T waves. Corresponding chest lead morphologies were inverted (35.5%), flat (19.6%), and biphasic (15.2%) T waves. CONCLUSIONS Our results indicate that QT evaluation by limb leads only underestimates the incidence of diLQTS experiencing TdP and favors the screening using both limb and chest lead ECG.
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Affiliation(s)
- Philipp Krisai
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Konstantinos Vlachos
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - F Daniel Ramirez
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Yosuke Nakatani
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Takashi Nakashima
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Takamitsu Takagi
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Tsukasa Kamakura
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Elodie Surget
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Clémentine André
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Ghassen Cheniti
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Nicolas Welte
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Rémi Chauvel
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Romain Tixier
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Josselin Duchateau
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Thomas Pambrun
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Nicolas Derval
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Mélèze Hocini
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Pierre Jaïs
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Michel Haïssaguerre
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Frédéric Sacher
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
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Santoni M, Occhipinti G, Romagnoli E, Miccini F, Scoccia L, Giulietti M, Principato G, Saladino T, Piva F, Battelli N. Different Cardiotoxicity of Palbociclib and Ribociclib in Breast Cancer: Gene Expression and Pharmacological Data Analyses, Biological Basis, and Therapeutic Implications. BioDrugs 2020; 33:613-620. [PMID: 31529317 DOI: 10.1007/s40259-019-00382-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Breast cancer is the most frequent tumor in women. The recent advent of cyclin-dependent kinase (CDK) 4/6 inhibitors palbociclib and ribociclib has represented a major step forward for patients with hormone receptor-positive breast cancer. These two agents have showed similar efficacy in terms of breast cancer outcome but different cardiotoxic effects. In particular, ribociclib, but not palbociclib, has been associated with QT interval prolongation, and the mechanisms underlying this event are still unclear. In order to clarify such difference, we matched the candidate genes associated with QT interval prolongation with genes whose expression is altered following palbociclib or ribociclib treatment. We also investigated whether pharmacokinetic and pharmacodynamic characteristics, such as IC50 (hERG) [concentration of drug producing 50% inhibition (human ether-à-go-go related gene)] and maximum concentration (Cmax), could justify the different effects on QT interval prolongation. Our results show that ribociclib, but not palbociclib, could act by down-regulating the expression of KCNH2 (encoding for potassium channel hERG) and up-regulating SCN5A and SNTA1 (encoding for sodium channels Nav1.5 and syntrophin-α1, respectively), three genes associated with long QT syndrome. Consistent with the cardiotoxicity induced by ribociclib, its IC50 (hERG)/free concentration (Cmax free) ratio is closer to the safety threshold than that of palbociclib. In summary, we hypothesize that the different cardiotoxicity associated with ribociclib and palbociclib could be due to the alteration of potassium and sodium channels induced by ribociclib. A better comprehension of the mechanisms of cardiac channelopathies and drug-induced QT interval prolongation will be fundamental to avoid serious and potentially lethal adverse events and, as a consequence, optimize the management of breast cancer patients.
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Affiliation(s)
- Matteo Santoni
- Oncology Unit, Macerata Hospital, via Santa Lucia 2, Macerata, Italy
| | - Giulia Occhipinti
- Department of Specialistic Clinical and Odontostomatological Sciences, Polytechnic University of Marche, Monte d'Ago, 60131, Ancona, Italy
| | | | - Francesca Miccini
- Oncology Unit, Macerata Hospital, via Santa Lucia 2, Macerata, Italy
| | | | - Matteo Giulietti
- Department of Specialistic Clinical and Odontostomatological Sciences, Polytechnic University of Marche, Monte d'Ago, 60131, Ancona, Italy
| | - Giovanni Principato
- Department of Specialistic Clinical and Odontostomatological Sciences, Polytechnic University of Marche, Monte d'Ago, 60131, Ancona, Italy
| | - Tiziana Saladino
- Oncology Unit, Macerata Hospital, via Santa Lucia 2, Macerata, Italy
| | - Francesco Piva
- Department of Specialistic Clinical and Odontostomatological Sciences, Polytechnic University of Marche, Monte d'Ago, 60131, Ancona, Italy.
| | - Nicola Battelli
- Oncology Unit, Macerata Hospital, via Santa Lucia 2, Macerata, Italy
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20
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Morissette P, Polak S, Chain A, Zhai J, Imredy JP, Wildey MJ, Travis J, Fitzgerald K, Fanelli P, Passini E, Rodriguez B, Sannajust F, Regan C. Combining an in silico proarrhythmic risk assay with a tPKPD model to predict QTc interval prolongation in the anesthetized guinea pig assay. Toxicol Appl Pharmacol 2020; 390:114883. [PMID: 31981640 PMCID: PMC7322544 DOI: 10.1016/j.taap.2020.114883] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/03/2020] [Accepted: 01/14/2020] [Indexed: 12/12/2022]
Abstract
Human-based in silico models are emerging as important tools to study the effects of integrating inward and outward ion channel currents to predict clinical proarrhythmic risk. The aims of this study were 2-fold: 1) Evaluate the capacity of an in silico model to predict QTc interval prolongation in the in vivo anesthetized cardiovascular guinea pig (CVGP) assay for new chemical entities (NCEs) and; 2) Determine if a translational pharmacokinetic/pharmacodynamic (tPKPD) model can improve the predictive capacity. In silico simulations for NCEs were performed using a population of human ventricular action potential (AP) models. PatchXpress® (PX) or high throughput screening (HTS) ion channel data from respectively n = 73 and n = 51 NCEs were used as inputs for the in silico population. These NCEs were also tested in the CVGP (n = 73). An M5 pruned decision tree-based regression tPKPD model was used to evaluate the concentration at which an NCE is liable to prolong the QTc interval in the CVGP. In silico results successfully predicted the QTc interval prolongation outcome observed in the CVGP with an accuracy/specificity of 85%/73% and 75%/77%, when using PX and HTS ion channel data, respectively. Considering the tPKPD predicted concentration resulting in QTc prolongation (EC5%) increased accuracy/specificity to 97%/95% using PX and 88%/97% when using HTS. Our results support that human-based in silico simulations in combination with tPKPD modeling can provide correlative results with a commonly used early in vivo safety assay, suggesting a path toward more rapid NCE assessment with reduced resources, cycle time, and animal use. Cardiac electrophysiological in silico model predicts QTc interval prolongation in the guinea pig. PKPD model predicts relevant QTc interval prolongation concentration in guinea pig. Combining the models improves the accuracy of predicting guinea pig QTc effects. Combining models accelerates assessment of QTc with lower resources and animal use.
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Affiliation(s)
- Pierre Morissette
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA.
| | - Sebastian Polak
- Certara UK Limited, Simcyp Division, Sheffield, UK; Jagiellonian University Medical College, Faculty of Pharmacy, Krakow, Poland
| | - Anne Chain
- Pharmacokinetics, Pharmacodynamics and Drug Metabolism (PPDM), Merck & Co., Inc., Rahway, NJ, USA
| | - Jin Zhai
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA
| | - John P Imredy
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA
| | - Mary Jo Wildey
- Pharmacology, Screening and Informatics, Merck & Co., Kenilworth, NJ, USA
| | - Jeffrey Travis
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA
| | - Kevin Fitzgerald
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA
| | - Patrick Fanelli
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA
| | - Elisa Passini
- Computational Cardiovascular Science Group, Department of Computer Science, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Blanca Rodriguez
- Computational Cardiovascular Science Group, Department of Computer Science, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Frederick Sannajust
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA
| | - Christopher Regan
- Safety Assessment & Laboratory Animal Resources (SALAR), Merck & Co., Inc., West Point, PA, USA
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21
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Hincapie-Castillo JM, Staley B, Henriksen C, Saidi A, Lipori GP, Winterstein AG. Development of a predictive model for drug-associated QT prolongation in the inpatient setting using electronic health record data. Am J Health Syst Pharm 2020; 76:1059-1070. [PMID: 31185072 DOI: 10.1093/ajhp/zxz100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE We aimed to construct a dynamic model for predicting severe QT interval prolongation in hospitalized patients using inpatient electronic health record (EHR) data. METHODS A retrospective cohort consisting of all adults admitted to 2 large hospitals from January 2012 through October 2013 was established. Thirty-five risk factors for severe QT prolongation (defined as a Bazett's formula-corrected QT interval [QTc] of ≥500 msec or a QTc increase of ≥60 msec from baseline) were operationalized for automated EHR retrieval; upon univariate analyses, 26 factors were retained in models for predicting the 24-hour risk of QT events on hospital day 1 (the Day 1 model) and on hospital days 2-5 (the Days 2-5 model). RESULTS A total of 1,672 QT prolongation events occurred over 165,847 days of risk exposure during the study period. C statistics were 0.828 for the Day 1 model and 0.813 for the Days 2-5 model. Patients in the upper 50th percentile of calculated risk scores experienced 755 of 799 QT events (94%) allocated in the Day 1 model and 804 of 873 QT events (92%) allocated in the Days 2-5 model. Among patients in the 90th percentile, the Day 1 and Days 2-5 models captured 351 of 799 (44%) and 362 of 873 (41%) QT events, respectively. CONCLUSION The risk models derived from EHR data for all admitted patients had good predictive validity. All risk factors were operationalized from discrete EHR fields to allow full automation for real-time identification of high-risk patients. Further research to test the models in other health systems and evaluate their effectiveness on outcomes and patient care in clinical practice is recommended.
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Affiliation(s)
- Juan M Hincapie-Castillo
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
| | | | - Carl Henriksen
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
| | - Arwa Saidi
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL
| | | | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
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22
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Fleseriu M, Pivonello R, Elenkova A, Salvatori R, Auchus RJ, Feelders RA, Geer EB, Greenman Y, Witek P, Cohen F, Biller BMK. Efficacy and safety of levoketoconazole in the treatment of endogenous Cushing's syndrome (SONICS): a phase 3, multicentre, open-label, single-arm trial. Lancet Diabetes Endocrinol 2019; 7:855-865. [PMID: 31542384 DOI: 10.1016/s2213-8587(19)30313-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Levoketoconazole is a ketoconazole stereoisomer in development for treatment of Cushing's syndrome and has not been assessed previously in a clinical trial in patients with Cushing's syndrome. We aimed to investigate the efficacy and safety of levoketoconazole in patients with endogenous Cushing's syndrome. METHODS SONICS is a phase 3, multicentre, open-label, non-randomised, single-arm study in which we recruited adults (≥18 years) with confirmed Cushing's syndrome and a mean 24-h urinary free cortisol (mUFC) of at least 1·5 times the upper limit of normal from 60 hospital and community sites in 19 countries (15 countries in Europe, and Canada, Israel, Turkey, and the USA). Patients were treated with oral levoketoconazole in a 2-21 week incremental dose-titration phase starting at 150 mg twice daily (150 mg increments until mUFC normalisation, maximum 600 mg twice daily) and a 6-month maintenance phase. The primary outcome was the proportion of patients with mUFC normalisation at end of maintenance, without dose increase during the maintenance phase (in the intention-to-treat population). Prespecified adverse events of special interest were potential liver toxicity, corrected QT prolongation, and adrenal insufficiency. This trial is registered with ClinicalTrials.gov, NCT01838551. FINDINGS Between July 30, 2014, and June 30, 2017, 201 individuals were screened and 94 patients were enrolled and received at least one dose of study medication. Of the 94 patients, 80 (85%) had pituitary Cushing's syndrome. Mean mUFC at baseline was 671·4 nmol/24 h (243·3 μg/24 h), which is 4·9 times the upper limit of normal. Of the 77 patients who advanced to the maintenance phase, 62 (81%) had mUFC normalisation by end-of-dose titration. At the end of the 6-month maintenance phase, 29 (31%) of 94 patients were responders; the least-squares mean estimate of the proportion of responders was 0·30 (95% CI 0·21-0·40; p=0·0154 vs null hypothesis of ≤0·20). The most common adverse events in the 94 patients were nausea (30 [32%]) and headache (26 [28%]). Adverse events led to study discontinuation in 12 (13%) of 94 patients. Two patients had a QT interval (Fridericia corrected) of more than 500 ms, and three patients had suspected adrenal insufficiency. Alanine aminotransferase reversibly increased to more than three times the upper limit of normal in ten (11%) patients. Four patients had serious adverse events that were considered probably or definitely related to the study drug: abnormal liver function test results (n=1), prolonged QT interval (n=2), and adrenal insufficiency (n=1). One person died from colon carcinoma unrelated to study medication. INTERPRETATION Twice-daily oral levoketoconazole treatment led to sustained improvements in urinary free cortisol, with an acceptable safety and tolerability profile. Levoketoconazole might represent a useful therapeutic option for the medical treatment of Cushing's syndrome. FUNDING Strongbridge Biopharma.
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Affiliation(s)
- Maria Fleseriu
- Department of Medicine and Neurological Surgery, Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università di Napoli Federico II, Naples, Italy
| | - Atanaska Elenkova
- Department of Endocrinology, Medical University Sofia, Sofia, Bulgaria
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes and Metabolism and Pituitary Center, Johns Hopkins University, Baltimore, MD, USA
| | - Richard J Auchus
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Richard A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Eliza B Geer
- Pituitary & Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yona Greenman
- Institute of Endocrinology and Metabolism, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Przemyslaw Witek
- Department of Gastroenterology, Endocrinology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | | | - Beverly M K Biller
- Neuroendocrine Clinical Center, Massachusetts General Hospital, Boston, MA, USA
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23
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Wells SP, Waddell HM, Sim CB, Lim SY, Bernasochi GB, Pavlovic D, Kirchhof P, Porrello ER, Delbridge LMD, Bell JR. Cardiomyocyte functional screening: interrogating comparative electrophysiology of high-throughput model cell systems. Am J Physiol Cell Physiol 2019; 317:C1256-C1267. [PMID: 31577512 DOI: 10.1152/ajpcell.00306.2019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cardiac arrhythmias of both atrial and ventricular origin are an important feature of cardiovascular disease. Novel antiarrhythmic therapies are required to overcome current drug limitations related to effectiveness and pro-arrhythmia risk in some contexts. Cardiomyocyte culture models provide a high-throughput platform for screening antiarrhythmic compounds, but comparative information about electrophysiological properties of commonly used types of cardiomyocyte preparations is lacking. Standardization of cultured cardiomyocyte microelectrode array (MEA) experimentation is required for its application as a high-throughput platform for antiarrhythmic drug development. The aim of this study was to directly compare the electrophysiological properties and responses to isoproterenol of three commonly used cardiac cultures. Neonatal rat ventricular myocytes (NRVMs), immortalized atrial HL-1 cells, and custom-generated human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) were cultured on microelectrode arrays for 48-120 h. Extracellular field potentials were recorded, and conduction velocity was mapped in the presence/absence of the β-adrenoceptor agonist isoproterenol (1 µM). Field potential amplitude and conduction velocity were greatest in NRVMs and did not differ in cardiomyocytes isolated from male/female hearts. Both NRVMs and hiPSC-CMs exhibited longer field potential durations with rate dependence and were responsive to isoproterenol. In contrast, HL-1 cells exhibited slower conduction and shorter field potential durations and did not respond to 1 µM isoproterenol. This is the first study to compare the intrinsic electrophysiologic properties of cultured cardiomyocyte preparations commonly used for in vitro electrophysiology assessment. These findings offer important comparative data to inform methodological approaches in the use of MEA and other techniques relating to cardiomyocyte functional screening investigations of particular relevance to arrhythmogenesis.
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Affiliation(s)
- Simon P Wells
- Department of Physiology, School of Biomedical Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, United Kingdom
| | - Helen M Waddell
- Department of Physiology, School of Biomedical Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Choon Boon Sim
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Shiang Y Lim
- St. Vincent's Institute of Medical Research, Fitzroy, Victoria, Australia.,Departments of Medicine and Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Gabriel B Bernasochi
- Department of Physiology, School of Biomedical Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Davor Pavlovic
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, United Kingdom
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, United Kingdom.,Departments of Cardiology, University Hospitals Birmingham and Sandwell and West Birmingham Hospitals National Health Service Trusts, Birmingham, United Kingdom
| | - Enzo R Porrello
- Department of Physiology, School of Biomedical Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Lea M D Delbridge
- Department of Physiology, School of Biomedical Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - James R Bell
- Department of Physiology, School of Biomedical Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Physiology, Anatomy and Microbiology, La Trobe University, Bundoora, Victoria, Australia
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Sutanto H, Laudy L, Clerx M, Dobrev D, Crijns HJ, Heijman J. Maastricht antiarrhythmic drug evaluator (MANTA): A computational tool for better understanding of antiarrhythmic drugs. Pharmacol Res 2019; 148:104444. [DOI: 10.1016/j.phrs.2019.104444] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/10/2019] [Accepted: 09/03/2019] [Indexed: 12/14/2022]
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25
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The Factors Associated with the Fatal Outcome of Stroke. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.2478/sjecr-2019-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
The aim of this study is to determine the risk factors associated with the fatal outcome of stroke. The research was designed as observational, non-interventional study, conducted by the type of case series, and it included 290 patients hospitalized with a diagnosis of stroke at Neurology Clinic of the Clinical Center Kragujevac during the observed period from 01/02/2013 to 31/01/2014. The data used for the research were: documentation of Neurology Clinic of the Clinical Center Kragujevac, documentation of the Institute of Public Health Kragujevac and patients’ questionnaires. The results of univariate binary logistic regression pointed out a relevant connection between the fatal outcome of stroke and age (p˂ 0.0001), gender (p˂ 0.0001), the severity of the disease (p = 0.002), smoking (p = 0.021), care for the parents’ health (p = 0.018), the concern about business problems (p = 0.018), while the influence of antidepressants was indicative (p = 0.066), whereas using the multivariate binary logistic regression, it was concluded that age (OR=1.096; 95% CI=1.059-1.134; p<0.001), the severity of the disease (OR=4.324; 95% CI=1.256-14.885; p=0.020) and the use of antidepressants (OR=5.578; 95% CI=1.178-26.423; p=0.030) were factors independently associated with the mortality rate. These findings suggest that it would be useful to carry out additional comprehensive research about all potential risk factors for the occurrence of stroke, and also to establish all the steps that can be taken in order to identify and detect risk factors, their elimination or reduction, and, accordingly, to take aggressive measures of primary and secondary prevention.
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26
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Liperoti R, Fusco D, Cipriani MC, Lo Monaco MR, Onder G. Balancing the risks and benefits of antipsychotic medications for symptom management in older patients with cancer. J Geriatr Oncol 2018; 9:693-695. [PMID: 30213455 DOI: 10.1016/j.jgo.2018.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 06/23/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Rosa Liperoti
- Department of Geriatrics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Domenico Fusco
- Department of Geriatrics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria C Cipriani
- Department of Geriatrics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria R Lo Monaco
- Department of Geriatrics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Graziano Onder
- Department of Geriatrics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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27
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Hemmeryckx B, Feng Y, Frederix L, Lox M, Trenson S, Vreeken R, Lu HR, Gallacher D, Ni Y, Lijnen HR. Evaluation of cardiac arrhythmic risks using a rabbit model of left ventricular systolic dysfunction. Eur J Pharmacol 2018; 832:145-155. [PMID: 29782862 DOI: 10.1016/j.ejphar.2018.05.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/17/2018] [Accepted: 05/17/2018] [Indexed: 12/13/2022]
Abstract
Patients with heart disease have a higher risk to develop cardiac arrhythmias, either spontaneously or drug-induced. In this study, we have used a rabbit model of myocardial infarction (MI) with severe left ventricular systolic dysfunction (LVSD) to study potential drug-induced cardiac risks with N-(piperidin-2-ylmethyl)-2,5-bis(2,2,2-trifluoroethoxy)benzamide (flecainide). Upon ligation of the left circumflex arteries, male New Zealand White rabbits developed a large MI and moderate or severe LVSD 7 weeks after surgery, in comparison to SHAM-operated animals. Subsequently, animals were exposed to escalating doses of flecainide (0.25-4 mg/kg) or solvent. Electrocardiograms (ECG) were recorded before surgery, 1 and 7 weeks after surgery and continuously during the drug protocol. The ECG biomarker iCEB (index of Cardio-Electrophysiological Balance = QT/QRS ratio) was calculated. During the ECG recording at week 1 and week 7 post MI, rabbits had no spontaneous cardiac arrhythmias. When rabbits were exposed to escalating doses of flecainide, 2 out of 5 rabbits with MI and moderate LVSD versus 0 out of 5 solvent-treated rabbits developed arrhythmias, such as ventricular tachycardia/ventricular fibrillation. These were preceded by a marked decrease of iCEB just before the onset (from 4.09 to 2.42 and from 5.56 to 2.25, respectively). Furthermore, 1 out of 5 MI rabbits with moderate LVSD and 1 out of 7 MI rabbits with severe LVSD developed total atrioventricular block after flecainide infusion and died. This rabbit model of MI and severe LVSD may be useful for preclinical evaluation of drug (similar mechanism as flecainide)-induced arrhythmic risks, which might be predicted by iCEB.
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Affiliation(s)
- Bianca Hemmeryckx
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
| | - Yuanbo Feng
- Radiology, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.
| | - Liesbeth Frederix
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
| | - Marleen Lox
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
| | - Sander Trenson
- Cardiology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
| | - Rob Vreeken
- Metabolomics, Pharmacokinetics, Dynamics and Metabolism Discovery Sciences, Janssen Pharmaceutical NV, Beerse, Belgium.
| | - Hua Rong Lu
- Translational Sciences, Safety Pharmacology Research, Janssen Research & Development, Janssen Pharmaceutical NV, Beerse, Belgium.
| | - David Gallacher
- Translational Sciences, Safety Pharmacology Research, Janssen Research & Development, Janssen Pharmaceutical NV, Beerse, Belgium.
| | - Yicheng Ni
- Radiology, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.
| | - H Roger Lijnen
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
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Associations of Neuropsychiatric Symptoms and Antidepressant Prescription with Survival in Alzheimer’s Disease. J Am Med Dir Assoc 2017; 18:1076-1081. [DOI: 10.1016/j.jamda.2017.07.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/13/2017] [Accepted: 07/05/2017] [Indexed: 01/13/2023]
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29
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Wiśniowska B, Lisowski B, Kulig M, Polak S. Drug interaction at hERG channel: In vitro assessment of the electrophysiological consequences of drug combinations and comparison against theoretical models. J Appl Toxicol 2017; 38:450-458. [DOI: 10.1002/jat.3552] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/24/2017] [Accepted: 09/24/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Barbara Wiśniowska
- Pharmacoepidemiology and Pharmacoeconomics Unit, Faculty of Pharmacy; Jagiellonian University Medical College; Medyczna 9, Str., 30-688 Kraków Poland
| | - Bartosz Lisowski
- Pharmacoepidemiology and Pharmacoeconomics Unit, Faculty of Pharmacy; Jagiellonian University Medical College; Medyczna 9, Str., 30-688 Kraków Poland
- M. Smoluchowski Institute of Physics; Jagiellonian University; Kraków Poland
- Department of Biophysics; Jagiellonian University Medical College; Kraków Poland
| | - Magdalena Kulig
- Pharmacoepidemiology and Pharmacoeconomics Unit, Faculty of Pharmacy; Jagiellonian University Medical College; Medyczna 9, Str., 30-688 Kraków Poland
| | - Sebastian Polak
- Pharmacoepidemiology and Pharmacoeconomics Unit, Faculty of Pharmacy; Jagiellonian University Medical College; Medyczna 9, Str., 30-688 Kraków Poland
- Simcyp (part of Certara); S2 4SU Sheffield UK
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30
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Radnic B, Radojevic N, Vucinic J, Duborija-Kovacevic N. The association between pro-arrhythmic agents and aortic stenosis in young adults: is it sufficient to clarify the sudden unexpected deaths? Cardiol Young 2017; 27:929-935. [PMID: 27821197 PMCID: PMC5422132 DOI: 10.1017/s1047951116001864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Most young patients with mild-to-moderate aortic stenosis show no symptoms, and sudden death appears only occasionally. We hypothesised that malignant ventricular arrhythmias could be responsible for the high incidence of sudden death in such patients. If multiple factors such as asymptomatic aortic stenosis in association with arrhythmia-provoking agents are involved, could it be sufficient to account for sudden unexpected death? In this study, eight cases of sudden death in young adults, with ages ranging from 22 to 36 years, who had never reported any symptoms that could be related to aortic stenosis, were investigated. Full autopsies were performed, and congenital aortic stenosis in all eight cases was confirmed. DNA testing for channelopathies was negative. Comprehensive toxicological analyses found an electrolyte imbalance, or non-toxic concentrations of amitriptyline, terfenadine, caffeine, and ethanol. Collectively, these results suggest that congenital asymptomatic aortic stenosis without cardiac hypertrophy in young adults is not sufficient to cause sudden death merely on its own; rather, an additional provoking factor is necessary. According to our findings, the provoking factor may be a state of physical or emotional stress, a state of electrolyte imbalance, or even taking a therapeutic dose of a particular drug.
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Affiliation(s)
- Bojana Radnic
- 1Institute of Forensic Medicine "Milovan Milovanovic",School of Medicine,University of Belgrade,Belgrade,Serbia
| | - Nemanja Radojevic
- 2Department of Forensic Medicine,Clinical Centre of Montenegro,Podgorica,Montenegro
| | - Jelena Vucinic
- 3Department of Pathology,Centre for Pathology and Forensic Medicine,Clinical Centre of Montenegro,Podgorica,Montenegro
| | - Natasa Duborija-Kovacevic
- 4Department of Pharmacology and Clinical Pharmacology,School of Medicine, University of Montenegro,Podgorica,Montenegro
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Masarone D, Limongelli G, Rubino M, Valente F, Vastarella R, Ammendola E, Gravino R, Verrengia M, Salerno G, Pacileo G. Management of Arrhythmias in Heart Failure. J Cardiovasc Dev Dis 2017; 4:E3. [PMID: 29367535 PMCID: PMC5715690 DOI: 10.3390/jcdd4010003] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 02/03/2017] [Accepted: 02/22/2017] [Indexed: 12/14/2022] Open
Abstract
Heart failure patients are predisposed to develop arrhythmias. Supraventricular arrhythmias can exacerbate the heart failure symptoms by decreasing the effective cardiac output and their control require pharmacological, electrical, or catheter-based intervention. In the setting of atrial flutter or atrial fibrillation, anticoagulation becomes paramount to prevent systemic or cerebral embolism. Patients with heart failure are also prone to develop ventricular arrhythmias that can present a challenge to the managing clinician. The management strategy depends on the type of arrhythmia, the underlying structural heart disease, the severity of heart failure, and the range from optimization of heart failure therapy to catheter ablation. Patients with heart failure, irrespective of ejection fraction are at high risk for developing sudden cardiac death, however risk stratification is a clinical challenge and requires a multiparametric evaluation for identification of patients who should undergo implantation of a cardioverter defibrillator. Finally, patients with heart failure can also develop symptomatic bradycardia, caused by sinus node dysfunction or atrio-ventricular block. The treatment of bradycardia in these patients with pacing is usually straightforward but needs some specific issue.
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Affiliation(s)
- Daniele Masarone
- Cardiologia SUN-Heart Failure Unit, Department of Cardiothoracic Sciences, Second University of Naples, via L. Bianchi, Naples 80100, Italy.
| | - Giuseppe Limongelli
- Cardiologia SUN-Heart Failure Unit, Department of Cardiothoracic Sciences, Second University of Naples, via L. Bianchi, Naples 80100, Italy.
| | - Marta Rubino
- Cardiologia SUN-Heart Failure Unit, Department of Cardiothoracic Sciences, Second University of Naples, via L. Bianchi, Naples 80100, Italy.
| | - Fabio Valente
- Cardiologia SUN-Heart Failure Unit, Department of Cardiothoracic Sciences, Second University of Naples, via L. Bianchi, Naples 80100, Italy.
| | - Rossella Vastarella
- Cardiologia SUN-Heart Failure Unit, Department of Cardiothoracic Sciences, Second University of Naples, via L. Bianchi, Naples 80100, Italy.
| | - Ernesto Ammendola
- Cardiologia SUN-Heart Failure Unit, Department of Cardiothoracic Sciences, Second University of Naples, via L. Bianchi, Naples 80100, Italy.
| | - Rita Gravino
- Cardiologia SUN-Heart Failure Unit, Department of Cardiothoracic Sciences, Second University of Naples, via L. Bianchi, Naples 80100, Italy.
| | - Marina Verrengia
- Cardiologia SUN-Heart Failure Unit, Department of Cardiothoracic Sciences, Second University of Naples, via L. Bianchi, Naples 80100, Italy.
| | - Gemma Salerno
- Cardiologia SUN-Heart Failure Unit, Department of Cardiothoracic Sciences, Second University of Naples, via L. Bianchi, Naples 80100, Italy.
| | - Giuseppe Pacileo
- Cardiologia SUN-Heart Failure Unit, Department of Cardiothoracic Sciences, Second University of Naples, via L. Bianchi, Naples 80100, Italy.
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Marill KA, Miller ES. Hypokalemia in women and methadone therapy are the strongest non-cardiologic factors associated with QT prolongation in an emergency department setting. J Electrocardiol 2017; 50:416-423. [PMID: 28274542 DOI: 10.1016/j.jelectrocard.2017.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Our primary objective was to determine the adjusted quantitative associations of clinical predictors with QT prolongation, a defining cause of Torsades de Pointes (TdP). METHODS A retrospective cohort study was performed on consecutive emergency department patients identified by ECG acquisition date, and heart rate corrected QT (QTc) and QRS durations. QTc was modeled as a function of clinical predictors with multiple linear regression. RESULTS 1010 patients were included. The strongest predictors of QTc and their coefficients were: antidysrhythmic (26.1ms, 95% CI 15.6-36.6) and methadone (43.6ms, 95% CI 28.1-59.2) therapies, and genetic long QT syndrome diagnosis (32.6ms, 95% CI -4.7-70.0). The association of QTc with serum potassium was approximated by a two piecewise linear function that differed by sex. For potassium below 3.9mmol/L, QTc increased by 43.0ms (95% CI 26.2-59.7) and 29.5ms (95% CI 19.1-40.0) for every 1mmol/L decrease in potassium in women and men, respectively. TdP occurred in only 4/686 (0.6%) of patients with QTc≥500 and QRS<120, but mortality during the visit including hospitalization was 8.0%. CONCLUSIONS QTc duration is highly sensitive to hypokalemia, particularly in women. Methadone prolongs QTc remarkably compared to other non-cardiologic medicines. QTc>500 with normal QRS often signifies profound illness and substantial mortality risk, though not necessarily imminent TdP.
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Affiliation(s)
- Keith A Marill
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Emily S Miller
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Sasaoka S, Matsui T, Hane Y, Abe J, Ueda N, Motooka Y, Hatahira H, Fukuda A, Naganuma M, Hasegawa S, Kinosada Y, Nakamura M. Time-to-Onset Analysis of Drug-Induced Long QT Syndrome Based on a Spontaneous Reporting System for Adverse Drug Events. PLoS One 2016; 11:e0164309. [PMID: 27723808 PMCID: PMC5056697 DOI: 10.1371/journal.pone.0164309] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 09/22/2016] [Indexed: 11/18/2022] Open
Abstract
Long QT syndrome (LQTS) is a disorder of the heart’s electrical activity that infrequently causes severe ventricular arrhythmias such as a type of ventricular tachycardia called torsade de pointes (TdP) and ventricular fibrillation, which can be fatal. There have been no previous reports on the time-to-onset for LQTS based on data from spontaneous reporting systems. The aim of this study was to assess the time-to-onset of LQTS according to drug treatment. We analyzed the association between 113 drugs in 37 therapeutic categories and LQTS including TdP using data obtained from the Japanese Adverse Drug Event Report database. For signal detection, we used the reporting odds ratio (ROR). Furthermore, we analyzed the time-to-onset data and assessed the hazard type using the Weibull shape parameter. The RORs (95% confidence interval) for bepridil, amiodarone, pilsicainide, nilotinib, disopyramide, arsenic trioxide, clarithromycin, cibenzoline, donepezil, famotidine, sulpiride, and nifekalant were 174.4 (148.6–204.6), 17.3 (14.7–20.4), 52.0 (43.4–62.4), 13.9 (11.5–16.7), 69.3 (55.3–86.8), 54.2 (43.2–68.0), 4.7 (3.8–5.8), 19.9 (15.9–25.0), 8.1 (6.5–10.1), 3.2 (2.5–4.1), 7.1 (5.5–9.2), and 254.8 (168.5–385.4), respectively. The medians and quartiles of time-to-onset for aprindine (oral) and bepridil were 20.0 (11.0–35.8) and 18.0 (6.0–43.0) days, respectively. The lower 95% confidence interval of the shape parameter β of bepridil was over 1 and the hazard was considered to increase over time.Our study indicated that the pattern of LQTS onset might differ among drugs. Based on these results, careful long-term observation is recommended, especially for specific drugs such as bepridil and aprindine. This information may be useful for the prevention of sudden death following LQTS and for efficient therapeutic planning.
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Affiliation(s)
- Sayaka Sasaoka
- Laboratory of Drug Informatics, Gifu Pharmaceutical University, Gifu-shi, Gifu, Japan
| | - Toshinobu Matsui
- Laboratory of Drug Informatics, Gifu Pharmaceutical University, Gifu-shi, Gifu, Japan
| | - Yuuki Hane
- Laboratory of Drug Informatics, Gifu Pharmaceutical University, Gifu-shi, Gifu, Japan
| | - Junko Abe
- Laboratory of Drug Informatics, Gifu Pharmaceutical University, Gifu-shi, Gifu, Japan
- Medical database Co., LTD, Shibuya-ku, Tokyo, Japan
| | - Natsumi Ueda
- Laboratory of Drug Informatics, Gifu Pharmaceutical University, Gifu-shi, Gifu, Japan
| | - Yumi Motooka
- Laboratory of Drug Informatics, Gifu Pharmaceutical University, Gifu-shi, Gifu, Japan
| | - Haruna Hatahira
- Laboratory of Drug Informatics, Gifu Pharmaceutical University, Gifu-shi, Gifu, Japan
| | - Akiho Fukuda
- Laboratory of Drug Informatics, Gifu Pharmaceutical University, Gifu-shi, Gifu, Japan
| | - Misa Naganuma
- Laboratory of Drug Informatics, Gifu Pharmaceutical University, Gifu-shi, Gifu, Japan
| | - Shiori Hasegawa
- Laboratory of Drug Informatics, Gifu Pharmaceutical University, Gifu-shi, Gifu, Japan
| | - Yasutomi Kinosada
- United Graduate School of Drug Discovery and Medical Information Sciences, Gifu University, Gifu-shi, Gifu, Japan
| | - Mitsuhiro Nakamura
- Laboratory of Drug Informatics, Gifu Pharmaceutical University, Gifu-shi, Gifu, Japan
- * E-mail:
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Chen Q, Qian HJ, Wang W, Zhang MQ, Lu DY, Lu C, Jin JM, Hu CY, Liu GY, Jia JY, Zheng HC, Li XN, Yu C, Wang YP, Liu Y. Pharmacokinetics, safety, and tolerability of sulcardine sulfate: an open-label, single-dose, randomized study in healthy Chinese subjects. Fundam Clin Pharmacol 2016; 31:120-125. [PMID: 27599871 DOI: 10.1111/fcp.12242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 08/31/2016] [Accepted: 09/02/2016] [Indexed: 01/28/2023]
Abstract
Sulcardine sulfate (Sul) is a novel anti-arrhythmic agent as a potential treatment for atrial fibrillation and ventricular arrhythmias. This study was conducted to investigate the pharmacokinetic profile, safety, and tolerability of Sul in healthy Chinese subjects. In this open-label, single-dose, randomized study, 10 healthy subjects were assigned to receive Sul doses of 200, 400, and 800 mg under fasting conditions (Cohorts A, B, and C, respectively) or 400 mg under fed conditions (Cohort D). The study incorporated a crossover design, separated by a seven-day washout period. Blood samples were collected before treatment and at successive time intervals up to 48 h after treatment. Sul concentrations in plasma samples were determined using a validated LC-MS/MS method. Tolerability was determined by clinical evaluation and adverse event (AE) monitoring. Pharmacokinetic results demonstrated that Cmax and AUC(0-t) of Sul increased with an increasing dose. The mean t1/2 values for Cohorts A, B, and C were 16.85, 17.66, and 11.87 h, respectively. No statistically significant differences were observed between men and women for the main pharmacokinetic parameters, with the exception of t1/2 in Cohorts B and C. No significant differences were observed in the absorption and bioavailability of Sul between the fed and fasted states (P > 0.05). Four subjects reported mild AEs during the study. No serious AEs were reported. Sul was shown to be safe and well tolerated in healthy Chinese subjects. Pharmacokinetics studies demonstrated that Sul has adequate oral absorption and bioavailability properties.
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Affiliation(s)
- Qian Chen
- Central Laboratory, Shanghai Xuhui Central Hospital/Zhongshan-Xuhui Hospital, Fudan University, Shanghai, 200031, China
| | - Hong-Jie Qian
- Central Laboratory, Shanghai Xuhui Central Hospital/Zhongshan-Xuhui Hospital, Fudan University, Shanghai, 200031, China
| | - Wei Wang
- Department of Emergency, Shanghai Xuhui Central Hospital/Zhongshan-Xuhui Hospital, Fudan University, Shanghai, 200031, China
| | - Meng-Qi Zhang
- Central Laboratory, Shanghai Xuhui Central Hospital/Zhongshan-Xuhui Hospital, Fudan University, Shanghai, 200031, China
| | - Dong-Ying Lu
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
| | - Chuan Lu
- Central Laboratory, Shanghai Xuhui Central Hospital/Zhongshan-Xuhui Hospital, Fudan University, Shanghai, 200031, China
| | - Jie-Mei Jin
- Central Laboratory, Shanghai Xuhui Central Hospital/Zhongshan-Xuhui Hospital, Fudan University, Shanghai, 200031, China
| | - Chao-Ying Hu
- Central Laboratory, Shanghai Xuhui Central Hospital/Zhongshan-Xuhui Hospital, Fudan University, Shanghai, 200031, China
| | - Gang-Yi Liu
- Central Laboratory, Shanghai Xuhui Central Hospital/Zhongshan-Xuhui Hospital, Fudan University, Shanghai, 200031, China
| | - Jing-Ying Jia
- Central Laboratory, Shanghai Xuhui Central Hospital/Zhongshan-Xuhui Hospital, Fudan University, Shanghai, 200031, China
| | - Hong-Chao Zheng
- Department of Cardiology, Shanghai Xuhui Central Hospital/Zhongshan-Xuhui Hospital, Fudan University, Shanghai, 200031, China
| | - Xue-Ning Li
- Department of Clinical Pharmacology, Zhong Shan Hospital, Fudan University, Shanghai, 200032, China
| | - Chen Yu
- Central Laboratory, Shanghai Xuhui Central Hospital/Zhongshan-Xuhui Hospital, Fudan University, Shanghai, 200031, China
| | - Yi-Ping Wang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
| | - Yun Liu
- Central Laboratory, Shanghai Xuhui Central Hospital/Zhongshan-Xuhui Hospital, Fudan University, Shanghai, 200031, China
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35
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Morissette P, Regan C, Fitzgerald K, Gerenser P, Travis J, Wang S, Fanelli P, Sannajust F. Shortening of the electromechanical window in the ketamine/xylazine-anesthetized guinea pig model to assess pro-arrhythmic risk in early drug development. J Pharmacol Toxicol Methods 2016; 81:171-82. [DOI: 10.1016/j.vascn.2016.06.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/23/2016] [Accepted: 06/04/2016] [Indexed: 11/26/2022]
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36
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Wang W, Qian HJ, Xin L, Zhang MQ, Lu DY, Jin JM, Liu GY, Jia JY, Zheng HC, Yu C, Wang YP, Zhu F, Liu Y. Multiple Dose Pharmacokinetics and Safety of Sulcardine Sulfate in Healthy Chinese Male Subjects: An Open-Label Phase I Clinical Study. Eur J Drug Metab Pharmacokinet 2016; 42:593-599. [PMID: 27550655 DOI: 10.1007/s13318-016-0370-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Sulcardine sulfate is a novel antiarrhythmic agent with mechanism of action as a multi-ion channel blocker. Preclinical studies in animal models have demonstrated that sulcardine sulfate is efficacious in atrial and ventricular arrhythmias, and consequently, leads to the prevention of sudden cardiac death. OBJECTIVES This study was conducted in healthy Chinese male subjects to investigate the pharmacokinetic profile and safety of sulcardine sulfate after repeated oral dose administration at 200, 400, and 800 mg for 5 days. METHODS Thirty-three male subjects were enrolled in this study. In the multiple dose phase, sulcardine sulfate was administered orally twice at the interval of q12 h since day 3. Sulcardine sulfate plasma concentration was determined using a validated LC-MS/MS method. Safety was assessed using clinical evaluation and AE monitoring. RESULTS In this repeated dose study, pharmacokinetic parameters (C max, AUC(0-t), and C ss_av) increased with the increase in dose (the dose ratio of the three cohorts was 1:2:4, while the ratio of C max and AUC(0-t) at day 1 was around 1:4:9 and 1:4:6, respectively), but in a non-linear fashion. The accumulation ratio at steady state (AR) of 200, 400, and 800 mg dose level was 1.18, 1.69, and 2.13, respectively, indicating that sulcardine sulfate has a modest accumulation upon repeated dose administration. Monitoring of pre-dose plasma concentrations on days 6, 7, and 8 for each dose level indicated that steady state was achieved at day 6 after three-day repeated dosing. CONCLUSIONS Pharmacokinetic characteristics of sulcardine sulfate were shown to be non-linear, with the modest accumulation upon repeated dosing, and sulcardine sulfate was safe and well tolerated.
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Affiliation(s)
- Wei Wang
- Emergency Ward, Shanghai Xuhui Central Hospital and Zhongshan-Xuhui Hospital, Fudan University and Shanghai Clinical Center, Chinese Academy of Science, Shanghai, China
| | - Hong-Jie Qian
- Central Laboratory, Shanghai Xuhui Central Hospital and Zhongshan-Xuhui Hospital, Fudan University and Shanghai Clinical Center, Chinese Academy of Science, Shanghai, China
| | - Liang Xin
- Central Laboratory, Shanghai Xuhui Central Hospital and Zhongshan-Xuhui Hospital, Fudan University and Shanghai Clinical Center, Chinese Academy of Science, Shanghai, China
| | - Meng-Qi Zhang
- Central Laboratory, Shanghai Xuhui Central Hospital and Zhongshan-Xuhui Hospital, Fudan University and Shanghai Clinical Center, Chinese Academy of Science, Shanghai, China
| | - Dong-Ying Lu
- Department of Pharmacology, State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Jie-Mei Jin
- Central Laboratory, Shanghai Xuhui Central Hospital and Zhongshan-Xuhui Hospital, Fudan University and Shanghai Clinical Center, Chinese Academy of Science, Shanghai, China
| | - Gang-Yi Liu
- Central Laboratory, Shanghai Xuhui Central Hospital and Zhongshan-Xuhui Hospital, Fudan University and Shanghai Clinical Center, Chinese Academy of Science, Shanghai, China
| | - Jing-Ying Jia
- Central Laboratory, Shanghai Xuhui Central Hospital and Zhongshan-Xuhui Hospital, Fudan University and Shanghai Clinical Center, Chinese Academy of Science, Shanghai, China
| | - Hong-Chao Zheng
- Department of Cardiology, Shanghai Xuhui Central Hospital and Zhongshan-Xuhui Hospital, Fudan University and Shanghai Clinical Center, Chinese Academy of Science, Shanghai, China
| | - Chen Yu
- Central Laboratory, Shanghai Xuhui Central Hospital and Zhongshan-Xuhui Hospital, Fudan University and Shanghai Clinical Center, Chinese Academy of Science, Shanghai, China
| | - Yi-Ping Wang
- Department of Pharmacology, State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Fu Zhu
- Department of Cardiology, Shanghai Xuhui Central Hospital and Zhongshan-Xuhui Hospital, Fudan University and Shanghai Clinical Center, Chinese Academy of Science, Shanghai, China.
| | - Yun Liu
- Central Laboratory, Shanghai Xuhui Central Hospital and Zhongshan-Xuhui Hospital, Fudan University and Shanghai Clinical Center, Chinese Academy of Science, Shanghai, China.
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37
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Two Sudden and Unexpected Deaths of Patients with Schizophrenia Associated with Intramuscular Injections of Antipsychotics and Practice Guidelines to Limit the Use of High Doses of Intramuscular Antipsychotics. Case Rep Psychiatry 2016; 2016:9406813. [PMID: 27597919 PMCID: PMC5002457 DOI: 10.1155/2016/9406813] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/03/2016] [Indexed: 12/12/2022] Open
Abstract
Intravenous haloperidol has been associated with torsades de pointes (TdP). These two sudden deaths were probable adverse drug reactions (ADRs) following intramuscular (IM) antipsychotics. The autopsies described lack of heart pathology and were highly compatible with the possibility of TdP in the absence of risk factors other than the accumulation of antipsychotics with a high serum peak after the last injection, leading to death within hours. The first case was a 27-year-old African-American male with schizophrenia but no medical issues. His death was probably caused by repeated IM haloperidol injections of 10 mg (totaling 35 mg in 2 days). The second case involves a 42-year-old African-American female with metabolic syndrome. Her probable cause of death was the last ziprasidone IM injection of 20 mg in addition to (1) three extra haloperidol doses (2 hours before the ziprasidone injection, 5 mg oral haloperidol; approximately 21 hours earlier, 5 mg oral haloperidol; and 2 days prior, one 10 mg IM haloperidol injection), (2) 10 mg/day of scheduled oral haloperidol for 6 days before death, and (3) a long-acting paliperidone injection of 156 mg 18 days before death. The study of haloperidol glucuronidation and its impairment in some African-Americans is urgently recommended.
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38
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Lee A, Pickham D. Basic Cardiac Electrophysiology and Common Drug-induced Arrhythmias. Crit Care Nurs Clin North Am 2016; 28:357-71. [PMID: 27484663 DOI: 10.1016/j.cnc.2016.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Drugs can be a double-edged sword, providing the benefit of symptom alleviation and disease modification but potentially causing harm from adverse cardiac arrhythmic events. Proarrhythmia is the ability of a drug to cause an arrhythmia, the number one reason for drugs to be withdrawn from the patient. Drug-induced arrhythmias are defined as the production of de novo arrhythmias or aggravation of existing arrhythmias, as a result of previous or concomitant pharmacologic treatment. This review summarizes normal cardiac cell and tissue functioning and provides an overview of drugs that effect cardiac repolarization and the adverse effects of commonly administered antiarrhythmics.
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Affiliation(s)
- Aimee Lee
- Cardiac Electrophysiology, Stanford Health Care, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - David Pickham
- General Medical Disciplines, Stanford Medicine, Stanford, CA, USA.
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Wang X, Tucker NR, Rizki G, Mills R, Krijger PH, de Wit E, Subramanian V, Bartell E, Nguyen XX, Ye J, Leyton-Mange J, Dolmatova EV, van der Harst P, de Laat W, Ellinor PT, Newton-Cheh C, Milan DJ, Kellis M, Boyer LA. Discovery and validation of sub-threshold genome-wide association study loci using epigenomic signatures. eLife 2016. [PMID: 27162171 DOI: 10.7554/elife.10557.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Genetic variants identified by genome-wide association studies explain only a modest proportion of heritability, suggesting that meaningful associations lie 'hidden' below current thresholds. Here, we integrate information from association studies with epigenomic maps to demonstrate that enhancers significantly overlap known loci associated with the cardiac QT interval and QRS duration. We apply functional criteria to identify loci associated with QT interval that do not meet genome-wide significance and are missed by existing studies. We demonstrate that these 'sub-threshold' signals represent novel loci, and that epigenomic maps are effective at discriminating true biological signals from noise. We experimentally validate the molecular, gene-regulatory, cellular and organismal phenotypes of these sub-threshold loci, demonstrating that most sub-threshold loci have regulatory consequences and that genetic perturbation of nearby genes causes cardiac phenotypes in mouse. Our work provides a general approach for improving the detection of novel loci associated with complex human traits.
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Affiliation(s)
- Xinchen Wang
- Department of Biology, Massachusetts Institute of Technology, Cambridge, United States.,Broad Institute of MIT and Harvard, Cambridge, United States.,Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, United States
| | - Nathan R Tucker
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Gizem Rizki
- Department of Biology, Massachusetts Institute of Technology, Cambridge, United States
| | - Robert Mills
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Peter Hl Krijger
- Hubrecht Institute-KNAW, University Medical Center Utrecht, Utrecht, Netherlands.,University Medical Center Utrecht, Utrecht, Netherlands
| | - Elzo de Wit
- Hubrecht Institute-KNAW, University Medical Center Utrecht, Utrecht, Netherlands.,University Medical Center Utrecht, Utrecht, Netherlands
| | - Vidya Subramanian
- Department of Biology, Massachusetts Institute of Technology, Cambridge, United States
| | - Eric Bartell
- Department of Biology, Massachusetts Institute of Technology, Cambridge, United States
| | - Xinh-Xinh Nguyen
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Jiangchuan Ye
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Jordan Leyton-Mange
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Elena V Dolmatova
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Pim van der Harst
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Wouter de Laat
- Hubrecht Institute-KNAW, University Medical Center Utrecht, Utrecht, Netherlands.,University Medical Center Utrecht, Utrecht, Netherlands
| | - Patrick T Ellinor
- Broad Institute of MIT and Harvard, Cambridge, United States.,Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Christopher Newton-Cheh
- Broad Institute of MIT and Harvard, Cambridge, United States.,Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States.,Center for Human Genetic Research, Massachusetts General Hospital, Boston, United States
| | - David J Milan
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Manolis Kellis
- Broad Institute of MIT and Harvard, Cambridge, United States.,Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, United States
| | - Laurie A Boyer
- Department of Biology, Massachusetts Institute of Technology, Cambridge, United States
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Wang X, Tucker NR, Rizki G, Mills R, Krijger PH, de Wit E, Subramanian V, Bartell E, Nguyen XX, Ye J, Leyton-Mange J, Dolmatova EV, van der Harst P, de Laat W, Ellinor PT, Newton-Cheh C, Milan DJ, Kellis M, Boyer LA. Discovery and validation of sub-threshold genome-wide association study loci using epigenomic signatures. eLife 2016; 5. [PMID: 27162171 PMCID: PMC4862755 DOI: 10.7554/elife.10557] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 04/04/2016] [Indexed: 12/31/2022] Open
Abstract
Genetic variants identified by genome-wide association studies explain only a modest proportion of heritability, suggesting that meaningful associations lie 'hidden' below current thresholds. Here, we integrate information from association studies with epigenomic maps to demonstrate that enhancers significantly overlap known loci associated with the cardiac QT interval and QRS duration. We apply functional criteria to identify loci associated with QT interval that do not meet genome-wide significance and are missed by existing studies. We demonstrate that these 'sub-threshold' signals represent novel loci, and that epigenomic maps are effective at discriminating true biological signals from noise. We experimentally validate the molecular, gene-regulatory, cellular and organismal phenotypes of these sub-threshold loci, demonstrating that most sub-threshold loci have regulatory consequences and that genetic perturbation of nearby genes causes cardiac phenotypes in mouse. Our work provides a general approach for improving the detection of novel loci associated with complex human traits. DOI:http://dx.doi.org/10.7554/eLife.10557.001 Most complex traits are governed by a large number of genetic contributors, each playing only a modest effect. This makes it difficult to identify the genetic variants that increase disease risk, hindering the discovery of new drug targets and the development of new therapeutics. To overcome this limitation in discovery power, the field of human genetics has traditionally sought increasingly large groups, or cohorts, of afflicted and non-afflicted individuals. Studies of large cohorts are a powerful approach for discovering new disease genes, but such groups are often impractical and sometimes impossible to obtain. However, it has become possible to complement the genetic evidence found in disease association studies with biological evidence of the effects of disease-associated genetic variants. Wang et al. focus specifically on genetic sites, or loci, that do not affect protein sequence but instead affect the non-coding control regions. These are known as enhancer elements, as they can enhance the expression of nearby genes. These loci constitute the majority of disease regions, and thus are extremely important, but their discovery has been hindered by our relatively poor understanding of the human genome. Chemical modifications known as epigenomic marks are indicative of enhancer regions. By studying the factors that affect heart rhythm, Wang et al. show that specific combinations of epigenomic marks are enriched in known trait-associated regions. This knowledge was then used to prioritize the further investigation of genetic regions that genome-wide association studies had only weakly linked to heart rhythm alterations. Wang et al. directly confirmed that genetic differences in “sub-threshold” regions indeed alter the activity of these regulatory regions in human heart cells. Furthermore, mutating or perturbing the predicted target genes of the sub-threshold enhancers caused heart defects in mouse and zebrafish. Wang et al. have demonstrated that epigenome maps can help to distinguish which sub-threshold regions from genome-wide association studies are more likely to contribute to a disease. This allows for the discovery of new disease genes with much smaller cohorts than would be needed otherwise, thus speeding up the development of new therapeutics by many years. DOI:http://dx.doi.org/10.7554/eLife.10557.002
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Affiliation(s)
- Xinchen Wang
- Department of Biology, Massachusetts Institute of Technology, Cambridge, United States.,Broad Institute of MIT and Harvard, Cambridge, United States.,Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, United States
| | - Nathan R Tucker
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Gizem Rizki
- Department of Biology, Massachusetts Institute of Technology, Cambridge, United States
| | - Robert Mills
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Peter Hl Krijger
- Hubrecht Institute-KNAW, University Medical Center Utrecht, Utrecht, Netherlands.,University Medical Center Utrecht, Utrecht, Netherlands
| | - Elzo de Wit
- Hubrecht Institute-KNAW, University Medical Center Utrecht, Utrecht, Netherlands.,University Medical Center Utrecht, Utrecht, Netherlands
| | - Vidya Subramanian
- Department of Biology, Massachusetts Institute of Technology, Cambridge, United States
| | - Eric Bartell
- Department of Biology, Massachusetts Institute of Technology, Cambridge, United States
| | - Xinh-Xinh Nguyen
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Jiangchuan Ye
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Jordan Leyton-Mange
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Elena V Dolmatova
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Pim van der Harst
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Wouter de Laat
- Hubrecht Institute-KNAW, University Medical Center Utrecht, Utrecht, Netherlands.,University Medical Center Utrecht, Utrecht, Netherlands
| | - Patrick T Ellinor
- Broad Institute of MIT and Harvard, Cambridge, United States.,Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Christopher Newton-Cheh
- Broad Institute of MIT and Harvard, Cambridge, United States.,Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States.,Center for Human Genetic Research, Massachusetts General Hospital, Boston, United States
| | - David J Milan
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States
| | - Manolis Kellis
- Broad Institute of MIT and Harvard, Cambridge, United States.,Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, United States
| | - Laurie A Boyer
- Department of Biology, Massachusetts Institute of Technology, Cambridge, United States
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Wiśniowska B, Tylutki Z, Wyszogrodzka G, Polak S. Drug-drug interactions and QT prolongation as a commonly assessed cardiac effect - comprehensive overview of clinical trials. BMC Pharmacol Toxicol 2016; 17:12. [PMID: 26960809 PMCID: PMC4785617 DOI: 10.1186/s40360-016-0053-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 02/15/2016] [Indexed: 01/10/2023] Open
Abstract
Background Proarrhythmia assessment is one of the major concerns for regulatory bodies and pharmaceutical industry. ICH guidelines recommending preclinical tests have been established in attempt to eliminate the risk of drug-induced arrhythmias. However, in the clinic, arrhythmia occurrence is determined not only by the inherent property of a drug to block ion currents and disturb electrophysiological activity of cardiac myocytes, but also by many other factors modifying individual risk of QT prolongation and subsequent proarrhythmia propensity. One of those is drug-drug interactions. Since polypharmacy is a common practice in clinical settings, it can be anticipated that there is a relatively high risk that the patient will receive at least two drugs mutually modifying their proarrhythmic potential and resulting either in triggering the occurrence or mitigating the clinical symptoms. The mechanism can be observed either directly at the pharmacodynamic level by competing for the molecular targets, or indirectly by modifying the physiological parameters, or at the pharmacokinetic level by alteration of the active concentration of the victim drug. Methods This publication provides an overview of published clinical studies on pharmacokinetic and/or pharmacodynamic drug-drug interactions in humans and their electrophysiological consequences (QT interval modification). Databases of PubMed and Scopus were searched and combinations of the following keywords were used for Title, Abstract and Keywords fields: interaction, coadministration, combination, DDI and electrocardiographic, QTc interval, ECG. Only human studies were included. Over 4500 publications were retrieved and underwent preliminary assessment to identify papers accordant with the topic of this review. 76 papers reporting results for 96 drug combinations were found and analyzed. Results The results show the tremendous variability of drug-drug interaction effects, which makes one aware of complexity of the problem, and suggests the need for assessment of an additional risk factors and careful ECG monitoring before administration of drugs with anticipated QT prolongation. Conclusions DDIs can play significant roles in drugs’ cardiac safety, as evidenced by the provided examples. Assessment of the pharmacodynamic effects of the drug interactions is more challenging as compared to the pharmacokinetic due to the significant diversity in the endpoints which should be analyzed specifically for various clinical effects. Nevertheless, PD components of DDIs should be accounted for as PK changes alone do not allow to fully explain the electrophysiological effects in clinic situations. Electronic supplementary material The online version of this article (doi:10.1186/s40360-016-0053-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Barbara Wiśniowska
- Unit of Pharmacoepidemiology and Pharmacoeconomics, Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Street, 30-688, Krakow, Poland.
| | - Zofia Tylutki
- Unit of Pharmacoepidemiology and Pharmacoeconomics, Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Street, 30-688, Krakow, Poland
| | - Gabriela Wyszogrodzka
- Department of Pharmaceutical Technology and Biopharmaceutics, Faculty of Pharmacy, Medical College, Jagiellonian University, Medyczna 9 Street, 30-688, Kraków, Poland
| | - Sebastian Polak
- Unit of Pharmacoepidemiology and Pharmacoeconomics, Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Street, 30-688, Krakow, Poland. .,Simcyp Ltd. (part of Certara), Blades Enterprise Centre, S2 4SU, Sheffield, UK.
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Abstract
Adverse drug reactions (ADRs) are a major public health concern and cause significant patient morbidity and mortality. Pharmacogenomics is the study of how genetic polymorphisms affect an individual's response to pharmacotherapy at the level of a whole genome. This article updates our knowledge on how genetic polymorphisms of important genes alter the risk of ADR occurrence after an extensive literature search. To date, at least 244 pharmacogenes identified have been associated with ADRs of 176 clinically used drugs based on PharmGKB. At least 28 genes associated with the risk of ADRs have been listed by the Food and Drug Administration as pharmacogenomic biomarkers. With the availability of affordable and reliable testing tools, pharmacogenomics looks promising to predict, reduce, and minimize ADRs in selected populations.
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Zhu W, Varga Z, Silva JR. Molecular motions that shape the cardiac action potential: Insights from voltage clamp fluorometry. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2015; 120:3-17. [PMID: 26724572 DOI: 10.1016/j.pbiomolbio.2015.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 11/11/2015] [Accepted: 12/16/2015] [Indexed: 01/04/2023]
Abstract
Very recently, voltage-clamp fluorometry (VCF) protocols have been developed to observe the membrane proteins responsible for carrying the ventricular ionic currents that form the action potential (AP), including those carried by the cardiac Na(+) channel, NaV1.5, the L-type Ca(2+) channel, CaV1.2, the Na(+)/K(+) ATPase, and the rapid and slow components of the delayed rectifier, KV11.1 and KV7.1. This development is significant, because VCF enables simultaneous observation of ionic current kinetics with conformational changes occurring within specific channel domains. The ability gained from VCF, to connect nanoscale molecular movement to ion channel function has revealed how the voltage-sensing domains (VSDs) control ion flux through channel pores, mechanisms of post-translational regulation and the molecular pathology of inherited mutations. In the future, we expect that this data will be of great use for the creation of multi-scale computational AP models that explicitly represent ion channel conformations, connecting molecular, cell and tissue electrophysiology. Here, we review the VCF protocol, recent results, and discuss potential future developments, including potential use of these experimental findings to create novel computational models.
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Affiliation(s)
- Wandi Zhu
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
| | - Zoltan Varga
- MTA-DE-NAP B Ion Channel Structure-Function Research Group, RCMM, University of Debrecen, Debrecen, Hungary
| | - Jonathan R Silva
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA.
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44
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Bossu A, van der Heyden MAG, de Boer TP, Vos MA. A 2015 focus on preventing drug-induced arrhythmias. Expert Rev Cardiovasc Ther 2015; 14:245-53. [DOI: 10.1586/14779072.2016.1116940] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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45
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Agámez Medina GL, González-Arévalo A, Gómez-Arnau JI, García del Valle S, Rubio JA, Esteban E, Pérez E. Effects of droperidol and ondansetron on dispersion of ventricular repolarization: A randomized double-blind clinical study in anesthetized adult patients. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:495-501. [PMID: 25887095 DOI: 10.1016/j.redar.2015.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 01/28/2015] [Accepted: 01/29/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Droperidol and ondansetron prolong QT interval, a circumstance that has raised some concerns regarding the possibility of inducing torsades de pointes (TdP). However drug-induced spatial dispersion of ventricular repolarization has been shown to be the principal arrhythmogenic substrate for TdP. The aim of this study is to explore the effects of droperidol and ondansetron on the dispersion of repolarization, measured using the T peak-to-end interval (Tp-e) and Tp-e/QT and Tp-e/RR(1/2) ratios in surgical anesthetized patients. METHODS A randomized, double-blind study carried out on sixty-three adult patients without cardiac disease or factors favoring QT prolongation and undergoing non-cardiac surgery were randomly assigned to the droperidol or ondansetron group. Under propofol anesthesia, a 12-lead EKG was obtained, and 1.25mg droperidol or 4mg ondansetron was injected. Five minutes later, a new 12-lead EKG was recorded. EKG analyses were independently performed by two cardiologists blinded to the state of the traces or group allocation. QT, RR and Tp-e intervals were measured by averaging five successive beats in leadII (QT) or V5 (Tp-e). The mean value for each measurement was calculated for statistical analysis. RESULTS Thirty-two patients (19 women) received droperidol, and 31 (22 women) ondansetron. Droperidol and ondansetron prolonged the QTcF interval (Fridericia formula) by 6.8 and 7.2ms (mean values) respectively, but neither droperidol nor ondansetron increased the Tp-e interval or Tp-e/QT and Tp-e/RR(1/2) ratios. CONCLUSION At antiemetic doses, neither ondansetron (4mg) nor droperidol (1.25mg) increases the dispersion of ventricular repolarization in healthy adult patients anesthetized with propofol.
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Affiliation(s)
- G L Agámez Medina
- Departamento de Anestesiología y Reanimación, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España.
| | - A González-Arévalo
- Departamento de Anestesiología y Reanimación, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - J I Gómez-Arnau
- Departamento de Anestesiología y Reanimación, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - S García del Valle
- Departamento de Anestesiología y Reanimación, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - J A Rubio
- Unidad de Cardiología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - E Esteban
- Unidad de Cardiología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - E Pérez
- Research Institute, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
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46
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Kim EJ, Han DW, Song MK, Choi SY, Kim SY. Effect-site concentration of remifentanil for attenuating QTc interval prolongation following intubation in hypertensive female patients. Acta Anaesthesiol Scand 2015; 59:1269-77. [PMID: 26104014 DOI: 10.1111/aas.12578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/28/2015] [Accepted: 05/28/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Haemodynamic changes after sympathetic stimuli like tracheal intubation are more pronounced in hypertensive patients than in normotensive patients. Heart rate (HR)-corrected QT (QTc) interval changes related to intubation may also be more prominent in hypertensive patients. We hypothesised that there would be a difference in the effect-site concentration (Ce) of remifentanil to attenuate QTc interval prolongation in normotensive and hypertensive patients following intubation. METHODS Twenty-two normotensive and 22 hypertensive female patients (≥ 50 year) were enrolled and anaesthesised with remifentanil and propofol using a target-controlled infusion. All hypertensive patients received oral antihypertensive medications for > 6 months and took the medications in the morning of the surgery. The effective concentration of remifentanil Ce in 50% (EC50 ) and 95% of the population (EC95 ) required to maintain QTc interval prolongation < 15 ms following intubation was calculated using the isotonic regression and a bootstrapping approach following the Dixon's up-and-down method. RESULTS Median duration of hypertension was 6 years. Isotonic regression revealed that the EC50 (83% confidence interval) of remifentanil Ce for reducing QTc interval prolongation following intubation was 3.8 (3.5-4.1) ng/ml in normotensive and 6.1 (5.8-6.2) ng/ml in hypertensive female patients. The EC95 (95% confidence interval) of remifentanil Ce was 4.4 (4.3-4.5) ng/ml in normotensive and 6.5 (6.4-6.5) ng/ml in hypertensive female patients. CONCLUSION The Ce of remifentanil required to attenuate QTc interval prolongation following intubation was significantly higher in hypertensive patients than it was in normotensive patients. Thus, more caution should be taken related to QTc interval prolongation when intubating hypertensive patients.
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Affiliation(s)
- E. J. Kim
- Department of Anaesthesiology and Pain Medicine; Severance Hospital; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Republic of Korea
| | - D. W. Han
- Department of Anaesthesiology and Pain Medicine; Severance Hospital; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Republic of Korea
| | - M. K. Song
- Department of Research Affairs; Biostatistics Collaboration Unit; Yonsei University College of Medicine; Seoul Republic of Korea
| | - S. Y. Choi
- Department of Anaesthesiology and Pain Medicine; Severance Hospital; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Republic of Korea
| | - S. Y. Kim
- Department of Anaesthesiology and Pain Medicine; Severance Hospital; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Republic of Korea
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Abstract
Severe malaria in pregnancy is a large contributor to maternal morbidity and mortality. Intravenous quinine has traditionally been the treatment drug of choice for severe malaria in pregnancy. However, recent randomized clinical trials (RCTs) indicate that intravenous artesunate is more efficacious for treating severe malaria, resulting in changes to the World Health Organization (WHO) treatment guidelines. Artemisinins, including artesunate, are embryo-lethal in animal studies and there is limited experience with their use in the first trimester. This review summarizes the current literature supporting 2010 WHO treatment guidelines for severe malaria in pregnancy and the efficacy, pharmacokinetics, and adverse event data for currently used antimalarials available for severe malaria in pregnancy. We identified ten studies on the treatment of severe malaria in pregnancy that reported clinical outcomes. In two studies comparing intravenous quinine with intravenous artesunate, intravenous artesunate was more efficacious and safe for use in pregnant women. No studies detected an increased risk of miscarriage, stillbirth, or congenital anomalies associated with first trimester exposure to artesunate. Although the WHO recommends using either quinine or artesunate for the treatment of severe malaria in first trimester pregnancies, our findings suggest that artesunate should be the preferred treatment option for severe malaria in all trimesters.
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48
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Paci M, Hyttinen J, Rodriguez B, Severi S. Human induced pluripotent stem cell-derived versus adult cardiomyocytes: an in silico electrophysiological study on effects of ionic current block. Br J Pharmacol 2015; 172:5147-60. [PMID: 26276951 PMCID: PMC4629192 DOI: 10.1111/bph.13282] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 07/29/2015] [Accepted: 08/03/2015] [Indexed: 12/28/2022] Open
Abstract
Background and Purpose Two new technologies are likely to revolutionize cardiac safety and drug development: in vitro experiments on human‐induced pluripotent stem cell‐derived cardiomyocytes (hiPSC‐CMs) and in silico human adult ventricular cardiomyocyte (hAdultV‐CM) models. Their combination was recently proposed as a potential replacement for the present hERG‐based QT study for pharmacological safety assessments. Here, we systematically compared in silico the effects of selective ionic current block on hiPSC‐CM and hAdultV‐CM action potentials (APs), to identify similarities/differences and to illustrate the potential of computational models as supportive tools for evaluating new in vitro technologies. Experimental Approach In silico AP models of ventricular‐like and atrial‐like hiPSC‐CMs and hAdultV‐CM were used to simulate the main effects of four degrees of block of the main cardiac transmembrane currents. Key Results Qualitatively, hiPSC‐CM and hAdultV‐CM APs showed similar responses to current block, consistent with results from experiments. However, quantitatively, hiPSC‐CMs were more sensitive to block of (i) L‐type Ca2+ currents due to the overexpression of the Na+/Ca2+ exchanger (leading to shorter APs) and (ii) the inward rectifier K+ current due to reduced repolarization reserve (inducing diastolic potential depolarization and repolarization failure). Conclusions and Implications In silico hiPSC‐CMs and hAdultV‐CMs exhibit a similar response to selective current blocks. However, overall hiPSC‐CMs show greater sensitivity to block, which may facilitate in vitro identification of drug‐induced effects. Extrapolation of drug effects from hiPSC‐CM to hAdultV‐CM and pro‐arrhythmic risk assessment can be facilitated by in silico predictions using biophysically‐based computational models.
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Affiliation(s)
- M Paci
- Department of Electronics and Communications Engineering, Tampere University of Technology, BioMediTech, Tampere, Finland
| | - J Hyttinen
- Department of Electronics and Communications Engineering, Tampere University of Technology, BioMediTech, Tampere, Finland
| | - B Rodriguez
- Department of Computer Science, University of Oxford, Oxford, UK
| | - S Severi
- Department of Electrical, Electronic and Information Engineering 'Guglielmo Marconi', University of Bologna, Cesena (FC), Italy
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Evans B, Cox A, Nicol E, Patil Mead M, Behr E. Drug-associated arrhythmia in the military patient. J ROY ARMY MED CORPS 2015; 161:253-8. [DOI: 10.1136/jramc-2015-000492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2015] [Indexed: 02/02/2023]
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50
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Choo WK, Turpie D, Milne K, Davidson L, Elofuke P, Whitfield J, Broadhurst P. Prescribers' practice of assessing arrhythmia risk with QT-prolonging medications. Cardiovasc Ther 2015; 32:209-13. [PMID: 24909270 DOI: 10.1111/1755-5922.12085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
AIMS This study aimed to assess prescribers' monitoring for arrhythmic risk with QT-prolonging medications (LQT drugs). METHODS Over a 6-month period, all inpatients under the care of Cardiologists (Cohort A) and General Physicians (Cohort B) at Aberdeen Royal Infirmary who were prescribed drugs with known risk of Torsades de Pointes (TdP) were identified. Admission and repeat electrocardiograms (ECG) after 48 h of commencing a LQT drug were examined. Actions taken if QTc was prolonged and drug-drug interactions were examined. A risk estimate on the UK hospital population was calculated. RESULTS Of the 4133 patients admitted during the study period, 234 (6%) patients were prescribed a LQT drug. There were 100 (43%) patients in Cohort A and 134 (57%) patients in Cohort B. Of those admitted with a pre-existing LQT drug prescription, an ECG was performed in 167 (96%) of patients and QTc prolongation was identified in 59 (34%). Of those who received a new prescription of LQT drug, 23 (38%) had QTc prolongation and more patients in Cohort A than Cohort B had a repeat ECG within 48 h (84% vs. 11%, P < 0.0001). QTc prolongation was only recognized in 6 (14%) and 2 (5%) patients in cohorts A and B, respectively. Only one patient at risk of drug interaction had QTc prolongation. None of our patients had documented TdP in hospital. Extrapolating these findings to the UK hospital population, at least 204 and <17-175 patients on cardiac and noncardiac LQT drugs, respectively, might be expected to have TdP each year. CONCLUSION Recognition of acquired QTc prolongation is poor. Clinician education and an electronic prescribing system may improve this situation.
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Affiliation(s)
- Wai Kah Choo
- Department of Cardiology, Aberdeen Royal Infirmary, Aberdeen, UK
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