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Meehan CP, White E, CVitan A, Jiang L, Wu WC, Wice M, Stafford J, Rudolph JL. Factors Associated With Early Palliative Care Among Patients With Heart Failure. J Palliat Med 2024. [PMID: 38608234 DOI: 10.1089/jpm.2023.0539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024] Open
Abstract
Background: Heart failure (HF) is a progressive, life-limiting illness for which palliative care (PC) is considered standard of care. Among patients that do receive PC, consultation tends to occur late in the illness course. Objective: Our primary aim was to examine patient factors associated with receiving PC in HF. Secondarily, we sought to determine factors associated with early PC encounters. Design: This was a retrospective cohort study of U.S. Veterans with prior hospitalization who died between January 1, 2011 and December 31, 2020. Setting/Subjects: Subjects were Veterans with HF who died with a prior admission to a Veterans Affairs hospital in the United States. Measurements: We calculated the time from PC encounter to death. We characterized HF patients who died without PC, with late PC (≤90 days before death), and with early PC (>90 days before death). Results: We identified 232,079 Veterans with a mean age of (76.5 ± 10.7) years. Within the cohort, 56.5% (n = 131,122) of Veterans died with no PC, 22.5% (n = 52,114) had PC <90 days before death, and 21.0% (n = 48,843) had PC >90 days before death. Veterans who died without PC tended to be younger with fewer comorbidities. Conclusions: While more than 20% of HF patients in our cohort had PC well in advance of death, more than half died without PC. PC involvement seemed to be driven by comorbidities rather than HF. Effective collaboration with Cardiology is needed to identify patients who would benefit from earlier PC involvement.
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Affiliation(s)
- Caroline P Meehan
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
| | - Emily White
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
| | - Alexander CVitan
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
| | - Lan Jiang
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Wen-Chih Wu
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Mitchell Wice
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Geriatrics and Extended Care, Providence VA Healthcare System, Providence, Rhode Island, USA
| | - Jensy Stafford
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - James L Rudolph
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Sebastian SA, Co EL, Mahtani A, Padda I, Anam M, Mathew SS, Shahzadi A, Niazi M, Pawar S, Johal G. Heart Failure: Recent Advances and Breakthroughs. Dis Mon 2024; 70:101634. [PMID: 37704531 DOI: 10.1016/j.disamonth.2023.101634] [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] [Indexed: 09/15/2023]
Abstract
Heart failure (HF) is a common clinical condition encountered in various healthcare settings with a vast socioeconomic impact. Recent advancements in pharmacotherapy have led to the evolution of novel therapeutic agents with a decrease in hospitalization and mortality rates in HF with reduced left ventricular ejection fraction (HFrEF). Lately, the introduction of artificial intelligence (AI) to construct decision-making models for the early detection of HF has played a vital role in optimizing cardiovascular disease outcomes. In this review, we examine the newer therapies and evidence behind goal-directed medical therapy (GDMT) for managing HF. We also explore the application of AI and machine learning (ML) in HF, including early diagnosis and risk stratification for HFrEF.
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Affiliation(s)
| | - Edzel Lorraine Co
- University of Santo Tomas Faculty of Medicine and Surgery, Manila, Philippines
| | - Arun Mahtani
- Richmond University Medical Center/Mount Sinai, Staten Island, New York, USA
| | - Inderbir Padda
- Richmond University Medical Center/Mount Sinai, Staten Island, New York, USA
| | - Mahvish Anam
- Deccan College of Medical Sciences, Hyderabad, India
| | | | | | - Maha Niazi
- Royal Alexandra Hospital, Edmonton, Canada
| | | | - Gurpreet Johal
- Department of Cardiology, University of Washington, Valley Medical Center, Seattle, Washington, USA
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Reduction in Ventricular Tachyarrhythmia Burden in Patients Enrolled in the RAID Trial. JACC Clin Electrophysiol 2022; 8:754-762. [PMID: 35738852 DOI: 10.1016/j.jacep.2022.02.018] [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: 10/28/2021] [Revised: 02/11/2022] [Accepted: 02/23/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND The RAID (Ranolazine Implantable Cardioverter-Defibrillator) randomized placebo-controlled trial showed that ranolazine treatment was associated with reduction in recurrent ventricular tachycardia (VT) requiring appropriate implantable cardioverter-defibrillator (ICD) therapy. OBJECTIVES This study aimed to identify groups of patients in whom ranolazine treatment would result in the highest reduction of ventricular tachyarrhythmia (VTA) burden. METHODS Andersen-Gill analyses were performed to identify variables associated with risk for VTA burden among 1,012 patients enrolled in RAID. The primary endpoint was VTA burden defined as VTA episodes requiring appropriate treatment. RESULTS Multivariate analysis identified 7 factors associated with increased VTA burden: history of VTA, age ≥65 years, New York Heart Association functional class ≥III, QRS complex (≥130 ms), low ejection fraction (<30%), atrial fibrillation (AF), and concomitant antiarrhythmic drug (AAD) therapy. The effect of ranolazine on VTA burden was seen among patients without concomitant AAD therapy (HR [HR]: 0.68; 95% CI: 0.55-0.84; P < 0.001), whereas no effect was seen among those who are concomitantly treated with other AADs (HR: 1.33; 95% CI: 0.90-1.96; P = 0.16); P = 0.003 for interaction. In patients with cardiac resynchronization therapy (CRT) ICDs, ranolazine treatment was associated with a 36% risk reduction for VTA recurrence (HR: 0.64; 95% CI: 0.47-0.86; P < 0.001), whereas among patients with ICDs without CRT no significant effect was noted (HR: 0.94; 95% CI: 0.74-1.18; P = 0.57); P = 0.047 for interaction. CONCLUSIONS In patients with high risk for VTA, ranolazine is effective in reducing VTA burden, with significantly greater effect in CRT-treated patients, those without AF, and those not treated with concomitant AADs. In patients already on AADs or those with AF, the addition of ranolazine did not affect VTA burden. (Ranolazine Implantable Cardioverter-Defibrillator Trial [RAID]; NCT01215253).
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Natterson-Horowitz B, Baccouche BM, Mary J, Shivkumar T, Bertelsen MF, Aalkjær C, Smerup MH, Ajijola OA, Hadaya J, Wang T. Did giraffe cardiovascular evolution solve the problem of heart failure with preserved ejection fraction? EVOLUTION MEDICINE AND PUBLIC HEALTH 2021; 9:248-255. [PMID: 34447575 PMCID: PMC8385250 DOI: 10.1093/emph/eoab016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 06/04/2021] [Indexed: 11/18/2022]
Abstract
The evolved adaptations of other species can be a source of insight for novel biomedical innovation. Limitations of traditional animal models for the study of some pathologies are fueling efforts to find new approaches to biomedical investigation. One emerging approach recognizes the evolved adaptations in other species as possible solutions to human pathology. The giraffe heart, for example, appears resistant to pathology related to heart failure with preserved ejection fraction (HFpEF)—a leading form of hypertension-associated cardiovascular disease in humans. Here, we postulate that the physiological pressure-induced left ventricular thickening in giraffes does not result in the pathological cardiovascular changes observed in humans with hypertension. The mechanisms underlying this cardiovascular adaptation to high blood pressure in the giraffe may be a bioinspired roadmap for preventive and therapeutic strategies for human HFpEF.
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Affiliation(s)
- Barbara Natterson-Horowitz
- Department of Medicine, Harvard Medical School, Boston, MA, USA.,Department of Human Evolutionary Biology, Harvard University, Cambridge, MA, USA.,Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Basil M Baccouche
- Department of Human Evolutionary Biology, Harvard University, Cambridge, MA, USA.,Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jennifer Mary
- Zoobiquity Research Initiative at UCLA, Los Angeles, CA 90024, USA
| | | | | | | | - Morten H Smerup
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Joseph Hadaya
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Molecular, Cellular and Integrative Physiology Program, UCLA, Los Angeles, CA, USA
| | - Tobias Wang
- Zoophysiology, Department of Biology, Aarhus University, Aarhus, Denmark
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Younis A, Goldberger JJ, Kutyifa V, Zareba W, Polonsky B, Klein H, Aktas MK, Huang D, Daubert J, Estes M, Cannom D, McNitt S, Stein K, Goldenberg I. Predicted benefit of an implantable cardioverter-defibrillator: the MADIT-ICD benefit score. Eur Heart J 2021; 42:1676-1684. [PMID: 33417692 PMCID: PMC8088341 DOI: 10.1093/eurheartj/ehaa1057] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/02/2020] [Accepted: 12/12/2020] [Indexed: 12/31/2022] Open
Abstract
AIMS The benefit of prophylactic implantable cardioverter-defibrillator (ICD) is not uniform due to differences in the risk of life-threatening ventricular tachycardia (VT)/ventricular fibrillation (VF) and non-arrhythmic mortality. We aimed to develop an ICD benefit prediction score that integrates the competing risks. METHODS AND RESULTS The study population comprised all 4531 patients enrolled in the MADIT trials. Best-subsets Fine and Gray regression analysis was used to develop prognostic models for VT (≥200 b.p.m.)/VF vs. non-arrhythmic mortality (defined as death without prior sustained VT/VF). Eight predictors of VT/VF (male, age < 75 years, prior non-sustained VT, heart rate > 75 b.p.m., systolic blood pressure < 140 mmHg, ejection fraction ≤ 25%, myocardial infarction, and atrialarrhythmia) and 7 predictors of non-arrhythmic mortality (age ≥ 75 years, diabetes mellitus, body mass index < 23 kg/m2, ejection fraction ≤ 25%, New York Heart Association ≥II, ICD vs. cardiac resynchronization therapy with defibrillator, and atrial arrhythmia) were identified. The two scores were combined to create three MADIT-ICD benefit groups. In the highest benefit group, the 3-year predicted risk of VT/VF was three-fold higher than the risk of non-arrhythmic mortality (20% vs. 7%, P < 0.001). In the intermediate benefit group, the difference in the corresponding predicted risks was attenuated (15% vs. 9%, P < 0.01). In the lowest benefit group, the 3-year predicted risk of VT/VF was similar to the risk of non-arrhythmic mortality (11% vs. 12%, P = 0.41). A personalized ICD benefit score was developed based on the distribution of the two competing risks scores in the study population (https://is.gd/madit). Internal and external validation confirmed model stability. CONCLUSIONS We propose the novel MADIT-ICD benefit score that predicts the likelihood of prophylactic ICD benefit through personalized assessment of the risk of VT/VF weighed against the risk of non-arrhythmic mortality.
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Affiliation(s)
- Arwa Younis
- Division of Cardiology, Department of Medicine, Clinical Cardiovascular Research Center, University of Rochester Medical Center, 265 Crittenden Blvd CU 420653, NY 14642, USA
| | - Jeffrey J Goldberger
- Division of Cardiology, Miller School of Medicine, University of Miami, 1321 NW 14th St #510, Miami, FL 33125, USA
| | - Valentina Kutyifa
- Division of Cardiology, Department of Medicine, Clinical Cardiovascular Research Center, University of Rochester Medical Center, 265 Crittenden Blvd CU 420653, NY 14642, USA
| | - Wojciech Zareba
- Division of Cardiology, Department of Medicine, Clinical Cardiovascular Research Center, University of Rochester Medical Center, 265 Crittenden Blvd CU 420653, NY 14642, USA
| | - Bronislava Polonsky
- Division of Cardiology, Department of Medicine, Clinical Cardiovascular Research Center, University of Rochester Medical Center, 265 Crittenden Blvd CU 420653, NY 14642, USA
| | - Helmut Klein
- Division of Cardiology, Department of Medicine, Clinical Cardiovascular Research Center, University of Rochester Medical Center, 265 Crittenden Blvd CU 420653, NY 14642, USA
| | - Mehmet K Aktas
- Division of Cardiology, Department of Medicine, Clinical Cardiovascular Research Center, University of Rochester Medical Center, 265 Crittenden Blvd CU 420653, NY 14642, USA
| | - David Huang
- Division of Cardiology, Department of Medicine, Clinical Cardiovascular Research Center, University of Rochester Medical Center, 265 Crittenden Blvd CU 420653, NY 14642, USA
| | - James Daubert
- Division of Cardiology, Duke Medicine Circle Clinic 2F/2G, Durham, NC 27710, USA
| | - Mark Estes
- Division of Cardiology, UPMC Heart and Vascular Institute 1350 Locust Street, Suite 100 Pittsburgh, PA 15219, USA
| | - David Cannom
- Division of Cardiology, Good Samaritan Hospital, 1245 Wilshire Blvd, Ste 703, Los Angeles, CA 90017, USA
| | - Scott McNitt
- Division of Cardiology, Department of Medicine, Clinical Cardiovascular Research Center, University of Rochester Medical Center, 265 Crittenden Blvd CU 420653, NY 14642, USA
| | - Kenneth Stein
- Cardiac Rhythm Management, Boston Scientific Corp., 4100 Hamline Ave N, St Paul, MN 55101, USA
| | - Ilan Goldenberg
- Division of Cardiology, Department of Medicine, Clinical Cardiovascular Research Center, University of Rochester Medical Center, 265 Crittenden Blvd CU 420653, NY 14642, USA
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Antol DD, Casebeer AW, DeClue RW, Stemkowski S, Russo PA. An Early View of Real-World Patient Response to Sacubitril/Valsartan: A Retrospective Study of Patients with Heart Failure with Reduced Ejection Fraction. Adv Ther 2018; 35:785-795. [PMID: 29777521 DOI: 10.1007/s12325-018-0710-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Sacubitril/valsartan has been established as an effective treatment for heart failure (HF) with reduced ejection fraction based on clinical trial data; however, little is known about its use or impact in real-world practice. METHODS This study included data from medical and pharmacy claims and medical records review for patients (n = 200) who initiated sacubitril/valsartan between August 2015 and March 2016 preceding issuance of American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) focused update on new pharmacological therapy for HF (May 2016), which included recommendations for sacubitril/valsartan. A within-subject analysis compared symptoms and healthcare resource utilization before and after treatment initiation. RESULTS Patients treated with sacubitril/valsartan had multiple comorbidities, and nearly all had previous treatment for HF. Most patients initiated sacubitril/valsartan at the lowest dose of 24/26 mg twice a day (BID), which remained unchanged during the observation period for half of the patients. During the first 6 weeks of treatment, few patients discontinued sacubitril/valsartan treatment (5.5%), and only 17% achieved the target dose of 97/103 mg BID after 4 months of treatment. The proportion of patients with ≥ 1 all-cause inpatient stay decreased significantly between the pre-initiation period (27.5%) and the post-initiation period (17.0%), P = 0.009. Fatigue was noted in 51.8% of patients pre-initiation and 39.5% post-initiation, P = 0.027. Shortness of breath was documented for 66.7% of patients pre-initiation and 51.8% post-initiation, P = 0.008. CONCLUSION The findings of this real-world investigation suggest sacubitril/valsartan is associated with symptom improvements and a reduction in hospitalizations within 4 months of treatment for patients with HF and reduced ejection fraction. FUNDING Novartis Pharmaceuticals Corporation.
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Kitai T, Tang WHW. Gut microbiota in cardiovascular disease and heart failure. Clin Sci (Lond) 2018; 132:85-91. [PMID: 29326279 PMCID: PMC6413501 DOI: 10.1042/cs20171090] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 11/15/2017] [Accepted: 11/20/2017] [Indexed: 02/07/2023]
Abstract
Accumulating evidence supports a relationship between the complexity and diversity of the gut microbiota and host diseases. In addition to alterations in the gut microbial composition, the metabolic potential of gut microbiota has been identified as a contributing factor in the development of diseases. Recent technological developments of molecular and biochemical analyses enable us to detect and characterize the gut microbiota via assessment and classification of its genomes and corresponding metabolites. These advances have provided emerging data supporting the role of gut microbiota in various physiological activities including host metabolism, neurological development, energy homeostasis, and immune regulation. Although few human studies have looked into the causative associations and underlying pathophysiology of the gut microbiota and host disease, a growing body of preclinical and clinical evidence supports the theory that the gut microbiota and its metabolites have the potential to be a novel therapeutic and preventative target for cardiovascular and metabolic diseases. In this review, we highlight the interplay between the gut microbiota and its metabolites, and the development and progression of hypertension, heart failure, and chronic kidney disease.
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Affiliation(s)
- Takeshi Kitai
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, U.S.A
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, U.S.A.
- Center for Clinical Genomics, Cleveland Clinic, Cleveland, OH, U.S.A
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Pharmacotherapy Choice Is Associated with 2-Year Mortality for Patients with Heart Failure and Reduced Ejection Fraction. Adv Ther 2017; 34:2345-2359. [PMID: 29019079 DOI: 10.1007/s12325-017-0618-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Factors associated with mortality for patients with heart failure and reduced ejection fraction (HFrEF) are known; however, the association between initial pharmacotherapy (IPT) and mortality is unclear in real-world settings. METHODS Using a retrospective design and claims database, 14,359 Medicare patients with HFrEF from August 2010 to July 2015 were identified. Index date was first HF claim. IPT was mono- or combo-angiotensin-converting enzyme inhibitor (ACEI), angiotensin II receptor blocker (ARB), beta-blocker (BB), hydralazine-nitrate (HN), and aldosterone antagonist (AA) within 1 year post-index. A multivariable time-dependent Cox model estimated associations between IPT and 2-year all-cause mortality. RESULTS Patients' median age was 76 (70-82) years; 45.1% were female. Within 1 month post-index, 61.4% had IPT, 6.1% started after the first month, and 32.4% had no IPT in the first year. Of IPTs, 47.5% were mono-vasodilators (ACEI, ARB or HN), 23.3% mono-vasodilator + BB, 16.9% mono-BB, and 3.5% triple therapy [(ACEI or ARB) + BB + (HN or AA)]. Two-year mortality rate was 27.9%. Compared to mono-vasodilator therapy, patients initiating triple therapy had 29.3% lower risk of 2-year mortality; those on mono-BB or no IPT had higher mortality risk. CONCLUSION IPT was associated with decreased 2-year mortality risk. Timely consideration of triple IPT therapies may be warranted once HFrEF diagnosis is confirmed. FUNDING Novartis Pharmaceuticals Corp. located in East Hanover, NJ, USA.
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Sawicka KM, Wawryniuk A, Zwolak A, Daniluk J, Szpringer M, Florek-Luszczki M, Drop B, Zolkowska D, Luszczki JJ. Influence of Ivabradine on the Anticonvulsant Action of Four Classical Antiepileptic Drugs Against Maximal Electroshock-Induced Seizures in Mice. Neurochem Res 2017; 42:1038-1043. [PMID: 28083847 PMCID: PMC5375969 DOI: 10.1007/s11064-016-2136-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 10/28/2016] [Accepted: 12/03/2016] [Indexed: 11/28/2022]
Abstract
Although the role of hyperpolarization-activated cyclic nucleotide-gated (HCN) channels in neuronal excitability and synaptic transmission is still unclear, it is postulated that the HCN channels may be involved in seizure activity. The aim of this study was to assess the effects of ivabradine (an HCN channel inhibitor) on the protective action of four classical antiepileptic drugs (carbamazepine, phenobarbital, phenytoin and valproate) against maximal electroshock-induced seizures in mice. Tonic seizures (maximal electroconvulsions) were evoked in adult male albino Swiss mice by an electric current (sine-wave, 25 mA, 0.2 s stimulus duration) delivered via auricular electrodes. Acute adverse-effect profiles of the combinations of ivabradine with classical antiepileptic drugs were measured in mice along with total brain antiepileptic drug concentrations. Results indicate that ivabradine (10 mg/kg, i.p.) significantly enhanced the anticonvulsant activity of valproate and considerably reduced that of phenytoin in the mouse maximal electroshock-induced seizure model. Ivabradine (10 mg/kg) had no impact on the anticonvulsant potency of carbamazepine and phenobarbital in the maximal electroshock-induced seizure test in mice. Ivabradine (10 mg/kg) significantly diminished total brain concentration of phenytoin and had no effect on total brain valproate concentration in mice. In conclusion, the enhanced anticonvulsant action of valproate by ivabradine in the mouse maximal electroshock-induced seizure model was pharmacodynamic in nature. A special attention is required when combining ivabradine with phenytoin due to a pharmacokinetic interaction and reduction of the anticonvulsant action of phenytoin in mice. The combinations of ivabradine with carbamazepine and phenobarbital were neutral from a preclinical viewpoint.
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Affiliation(s)
| | | | | | | | | | | | | | - Dorota Zolkowska
- School of Medicine, University of California-Davis, Sacramento, California, USA
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