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Zeitler EP, Poole JE, Albert CM, Al-Khatib SM, Ali-Ahmed F, Birgersdotter-Green U, Cha YM, Chung MK, Curtis AB, Hurwitz JL, Lampert R, Sandhu RK, Shaik F, Sullivan E, Tamirisa KP, Santos Volgman A, Wright JM, Russo AM. Arrhythmias in Female Patients: Incidence, Presentation and Management. Circ Res 2022; 130:474-495. [PMID: 35175839 DOI: 10.1161/circresaha.121.319893] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
There is a growing appreciation for differences in epidemiology, treatment, and outcomes of cardiovascular conditions by sex. Historically, cardiovascular clinical trials have under-represented females, but findings have nonetheless been applied to clinical care in a sex-agnostic manner. Thus, much of the collective knowledge about sex-specific cardiovascular outcomes result from post hoc and secondary analyses. In some cases, these investigations have revealed important sex-based differences with implications for optimizing care for female patients with arrhythmias. This review explores the available evidence related to cardiac arrhythmia care among females, with emphasis on areas in which important sex differences are known or suggested. Considerations related to improving female enrollment in clinical trials as a way to establish more robust clinical evidence for the treatment of females are discussed. Areas of remaining evidence gaps are provided, and recommendations for areas of future research and specific action items are suggested. The overarching goal is to improve appreciation for sex-based differences in cardiac arrhythmia care as 1 component of a comprehensive plan to optimize arrhythmia care for all patients.
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Affiliation(s)
- Emily P Zeitler
- The Geisel School of Medicine at Dartmouth, Hanover, NH (E.P.Z.).,Division of Cardiology, Dartmouth-Hitchcock Medical Center, The Dartmouth Institute, Lebanon, NH (E.P.Z.)
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle (J.E.P.)
| | - Christine M Albert
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Hospital, Los Angeles, CA (C.M.A., R.K.S.)
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.M.A.-K.)
| | | | | | - Yong-Mei Cha
- Mayo Clinic, St Mary's Campus, Rochester, MN (F.A.-A., Y.-M.C.)
| | | | - Anne B Curtis
- Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo General Medical Center, NY (A.B.C.)
| | | | - Rachel Lampert
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (R.L.)
| | - Roopinder K Sandhu
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Hospital, Los Angeles, CA (C.M.A., R.K.S.)
| | - Fatima Shaik
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ (F.S., A.M.R.)
| | | | | | | | - Jennifer M Wright
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI (J.M.W.)
| | - Andrea M Russo
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ (F.S., A.M.R.)
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Doggrell SA, Hancox JC. Cardiac safety concerns for domperidone, an antiemetic and prokinetic, and galactogogue medicine. Expert Opin Drug Saf 2013; 13:131-8. [PMID: 24147629 DOI: 10.1517/14740338.2014.851193] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Domperidone is a dopamine D2-receptor antagonist developed as an antiemetic and prokinetic agent. Oral domperidone is not approved in the United States, but it is used in many countries to treat nausea and vomiting, gastroparesis and as a galactogogue (to promote lactation). The US Food and Drug Administration (FDA) have issued a warning about the cardiac safety of domperidone. AREAS COVERED The authors undertook a review of the cardiac safety of oral domperidone. EXPERT OPINION The data from preclinical studies are unambiguous in identifying domperidone as able to produce marked hERG channel inhibition and action potential prolongation at clinically relevant concentrations. The compound's propensity to augment instability of action potential duration and action potential triangulation are also indicative of proarrhythmic potential. Domperidone should not be administered to subjects with pre-existing QT prolongation/LQTS, subjects receiving drugs that inhibit CYP3A4, subjects with electrolyte abnormalities or with other risk factors for QT-prolongation. With these provisos, it is possible that domperidone may be used as a galactogogue without direct risk to healthy breast feeding women, but more safety information should be sought in this situation. Also, more safety information is required regarding risk to breast feeding infants before domperidone is routinely used in gastroparesis or gastroesphageal reflux in children.
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Affiliation(s)
- Sheila A Doggrell
- Queensland University of Technology, School of Biomedical Sciences, Faculty of Health , Brisbane, QLD4002 , Australia +61 7 3138 2015 ; +61 7 3138 1534 ;
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Lowe JS, Stroud DM, Yang T, Hall L, Atack TC, Roden DM. Increased late sodium current contributes to long QT-related arrhythmia susceptibility in female mice. Cardiovasc Res 2012; 95:300-7. [PMID: 22562703 DOI: 10.1093/cvr/cvs160] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
AIMS Female gender is a risk factor for long QT-related arrhythmias, but the underlying mechanisms remain uncertain. Here, we tested the hypothesis that gender-dependent function of the post-depolarization 'late' sodium current (I(Na-L)) contributes. METHODS AND RESULTS Studies were conducted in mice in which the canonical cardiac sodium channel Scn5a locus was disrupted, and expression of human wild-type SCN5A cDNA substituted. Baseline QT intervals were similar in male and female mice, but exposure to the sodium channel opener anemone toxin ATX-II elicited polymorphic ventricular tachycardia in 0/9 males vs. 6/9 females. Ventricular I(Na-L) and action potential durations were increased in myocytes isolated from female mice compared with those from males before and especially after treatment with ATX-II. Further, ATX-II elicited potentially arrhythmogenic early afterdepolarizations in myocytes from 0/5 male mice and 3/5 female mice. CONCLUSION These data identify variable late I(Na) as a modulator of gender-dependent arrhythmia susceptibility.
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Affiliation(s)
- John S Lowe
- Department of Medicine, Vanderbilt University School of Medicine, 2215B Garland Avenue, Nashville, TN 37232-0575, USA
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Himmel HM, Bussek A, Hoffmann M, Beckmann R, Lohmann H, Schmidt M, Wettwer E. Field and action potential recordings in heart slices: correlation with established in vitro and in vivo models. Br J Pharmacol 2012; 166:276-96. [PMID: 22074238 PMCID: PMC3415654 DOI: 10.1111/j.1476-5381.2011.01775.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 09/23/2011] [Accepted: 09/29/2011] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND PURPOSE Action potential (AP) recordings in ex vivo heart preparations constitute an important component of the preclinical cardiac safety assessment according to the ICH S7B guideline. Most AP measurement models are sensitive, predictive and informative but suffer from a low throughput. Here, effects of selected anti-arrhythmics (flecainide, quinidine, atenolol, sotalol, dofetilide, nifedipine, verapamil) on field/action potentials (FP/AP) of guinea pig and rabbit ventricular slices are presented and compared with data from established in vitro and in vivo models. EXPERIMENTAL APPROACH Data from measurements of membrane currents (hERG, I(Na) ), AP/FP (guinea pig and rabbit ventricular slices), AP (rabbit Purkinje fibre), haemodynamic/ECG parameters (conscious, telemetered dog) were collected, compared and correlated to complementary published data (focused literature search). KEY RESULTS The selected anti-arrhythmics, flecainide, quinidine, atenolol, sotalol, dofetilide, nifedipine and verapamil, influenced the shape of AP/FP of guinea pig and rabbit ventricular slices in a manner similar to that observed for rabbit PF. The findings obtained from slice preparations are in line with measurements of membrane currents in vitro, papillary muscle AP in vitro and haemodynamic/ECG parameters from conscious dogs in vivo, and were also corroborated by published data. CONCLUSION AND IMPLICATIONS FP and AP recordings from heart slices correlated well with established in vitro and in vivo models in terms of pharmacology and predictability. Heart slice preparations yield similar results as papillary muscle but offer enhanced throughput for mechanistic investigations and may substantially reduce the use of laboratory animals.
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Sex differences in drug disposition. J Biomed Biotechnol 2011; 2011:187103. [PMID: 21403873 PMCID: PMC3051160 DOI: 10.1155/2011/187103] [Citation(s) in RCA: 189] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Revised: 12/20/2010] [Accepted: 01/05/2011] [Indexed: 12/17/2022] Open
Abstract
Physiological, hormonal, and genetic differences between males and females affect the prevalence, incidence, and severity of diseases and responses to therapy. Understanding these differences is important for designing safe and effective treatments. This paper summarizes sex differences that impact drug disposition and includes a general comparison of clinical pharmacology as it applies to men and women.
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Nicolson TJ, Mellor HR, Roberts RRA. Gender differences in drug toxicity. Trends Pharmacol Sci 2010; 31:108-14. [PMID: 20117848 DOI: 10.1016/j.tips.2009.12.001] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Revised: 11/16/2009] [Accepted: 12/01/2009] [Indexed: 11/27/2022]
Abstract
Clinical data suggest that gender dimorphic profiles are emerging in terms of both drug efficacy and adverse drug reactions (ADRs). With an increasing emphasis on individualised therapies and the need to prevent drug attrition there is a compelling need to understand the molecular basis for gender dimorphic profiles in ADRs and the consequences. Classes of agents exhibiting gender-based variation in pharmaceutical efficacy and toxicity include anaesthetics, HIV-1 therapies and antiarrhythmic drugs. Body weight differences are often cited as a reason for differences in drug pharmacokinetics and subsequent toxicity. However, some studies accounted for these factors and still found significance suggesting that dosage versus body weight does not explain the outcome. Here, we present an overview of current understanding of gender-specific drug toxicity and present rational molecular explanations for these adverse events. There is mounting evidence in support of hormonal effects underpinning the majority of the ADR differences observed between the sexes.
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Affiliation(s)
- Tamara J Nicolson
- General Toxicology Sciences, Safety Assessment UK, AstraZeneca R&D, Alderley Park, Macclesfield, Cheshire, SK10 4TG, UK.
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