Pharmacological and non pharmacological strategies in the management of coronary artery disease and chronic kidney disease

Updates in the Management of Coronary Artery Disease: A Review Article

Coronary artery disease (CAD) remains a significant health challenge, imposing substantial burdens on individuals and healthcare systems worldwide. CAD's impact stems from artery narrowing and blockage, leading to severe complications like heart attacks and heart failure. Collaborative efforts by researchers, professionals, and governments have fostered advancements in comprehending and managing this cardiovascular ailment. Evolving CAD management embraces modern diagnostics, cutting-edge pharmaceuticals, invasive procedures, lifestyle modifications, and cardiac rehabilitation. This comprehensive approach aims to amplify outcomes and elevate the quality of life for CAD-affected individuals. This review delves into innovative treatments, pivotal breakthroughs, and recent trends in clinical practices that collectively shape CAD management. The exploration encompasses novel diagnostic technologies enabling early detection and risk assessment. Moreover, it investigates recent breakthroughs in medications that profoundly impact platelet disorders, lipid reduction, and angina. Precision medicine's role in tailoring treatment strategies based on patient characteristics is thoroughly examined. Advances in invasive procedures, like percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), have revolutionised coronary revascularisation, substantially improved long-term outcomes, and reduced restenosis rates. The increasing significance of lifestyle changes and cardiac rehabilitation in CAD management, augmenting treatment options and patient recovery, are meticulously scrutinized. While these strides are pivotal, research continues to chart new paths in CAD management, from innovative drugs to collaborative multidisciplinary care models. Staying attuned to the latest advancements and embracing a patient-centric approach can collectively reduce CAD's impact and facilitate the lives of those grappling with this chronic cardiovascular disorder.

Mapping the global research landscape on malnutrition for patients with chronic kidney disease: a visualization analysis

BACKGROUND

Chronic kidney disease (CKD) is seen as a diverse disease and a primary contributor to global mortality. Malnutrition arises within chronic illness, which involves protein energy depletion and inadequate levels of essential nutrients. These factors increase the likelihood of death and the overall impact of the disease on affected individuals. Consequently, this study aims to utilize bibliometric and visual analysis to assess the current state of research, the latest advances and emerging patterns in the fields of CKD and malnutrition.

METHODS

Extensive research was conducted using the Scopus database, which is the most authoritative database of research publications and citations, to focus on CKD research between 2003 and 2022, as indicated by title and author keywords. Then, within this vast collection of academic publications, a notable subset of articles was exclusively dedicated to investigating the relationship between CKD and malnutrition. Finally, we performed bibliometric analysis and visualization using VOSviewer 1.6.19 and Microsoft Excel 2013.

RESULTS

Large global research between 2003 and 2022 resulted in 50,588 documents focused on CKD, as indicated by title and author keywords. In this extensive collection of scientific publications, a staggering portion of 823 articles is devoted exclusively to investigating the link between CKD and malnutrition. Further analysis reveals that this body of work consists of 565 articles (68.65%), 221 reviews (26.85%), and 37 miscellaneous entries (4.50%), which encompass letters and editorials. The USA was found to be the most productive country (n = 173; 21.02%), followed by Italy (n = 83; 10.09%), Sweden (n = 56; 6.80%), Brazil (n = 54; 6.56%) and China (n = 51; 6.20%). The most common terms on the map include those related to the topic of (a) malnutrition in hemodialysis patients and predicting factors; terms associated with the (b) impact of malnutrition on cardiovascular risk and complications in CKD patients; and terms related to the (c) dietary protein intake and malnutrition in CKD.

CONCLUSIONS

This study is the first of its kind to analyze CKD and malnutrition research using data from Scopus for visualization and network mapping. Recent trends indicate an increasing focus on protein-energy wasting/malnutrition in hemodialysis patients and predicting factors, dietary protein intake, and malnutrition in CKD. These topics have gained significant attention and reflect the latest scientific advances. Intervention studies are crucial to examining diet therapy's impact on patients with stages 1 to 5 CKD. We hope this study will offer researchers, dietitians and nephrologists valuable information.

Eptifibatide, an Older Therapeutic Peptide with New Indications: From Clinical Pharmacology to Everyday Clinical Practice

Therapeutic peptides are oligomers or short polymers of amino acids used for various medical purposes. Peptide-based treatments have evolved considerably due to new technologies, stimulating new research interests. They have been shown to be beneficial in a variety of therapeutic applications, notably in the treatment of cardiovascular disorders such as acute coronary syndrome (ACS). ACS is characterized by coronary artery wall damage and consequent formation of an intraluminal thrombus obstructing one or more coronary arteries, leading to unstable angina, non-ST elevated myocardial infarction, and ST-elevated myocardial infarction. One of the promising peptide drugs in the treatment of these pathologies is eptifibatide, a synthetic heptapeptide derived from rattlesnake venom. Eptifibatide is a glycoprotein IIb/IIIa inhibitor that blocks different pathways in platelet activation and aggregation. In this narrative review, we summarized the current evidence on the mechanism of action, clinical pharmacology, and applications of eptifibatide in cardiology. Additionally, we illustrated its possible broader usage with new indications, including ischemic stroke, carotid stenting, intracranial aneurysm stenting, and septic shock. Further research is, however, required to fully evaluate the role of eptifibatide in these pathologies, independently and in comparison to other medications.

Gender-Disparities in the in-Hospital Clinical Outcome Among Patients with Chronic Kidney Disease Undergoing Percutaneous Coronary Intervention

PURPOSE

The current study was to evaluate the gender-disparities in the in-hospital thrombotic and bleeding events among patients with chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI).

PATIENTS AND METHODS

Patients with CKD undergoing PCI were retrospectively enrolled. Baseline characteristics, and thrombotic and bleeding events occurred during hospitalization were collected and compared by gender.

RESULTS

Compared to males (n = 558), females (n = 402) were older and more likely to have diabetes mellitus (37.1% vs 29.7%). Females had a lower estimated glomerular filtration rate (eGFR; 51.2 ± 7.9 vs 54.6 ± 5.1 mL/min/1.73m2) and were more likely to undergo urgent PCI (66.7% vs 60.2%) and use glycoprotein IIb/IIIa inhibitor (15.4% vs 7.5%) at peri-PCI period. Compared to males, females had a higher rate of in-hospital mortality which was due to thrombotic events (9.0% vs 3.4%). Females also had a higher rate of moderate-to-severe hemorrhage (8.0% vs 3.2%). After multivariable adjustment, diabetes mellitus (odds ratio [OR] 1.15 and 95% confidence interval [CI] 1.07-1.29) and acute coronary syndrome (ACS) presentation (OR 1.53 and 95% CI 1.34-1.93) were associated with gender-disparities in composite thrombotic events. Ageing (OR 1.10 and 95% CI 1.02-1.33), diabetes mellitus (OR 1.21 and 95% CI 1.07-1.40) and glycoprotein IIb/IIIa inhibitor use (OR 1.13 and 95% CI 1.02-1.28) were associated with composite bleeding events.

CONCLUSION

Females with CKD undergoing PCI had a higher risk of experiencing in-hospital thrombotic and bleeding events than males.

Risk Factors of Cardiac Death for Elderly Patients with Severe Chronic Kidney Disease after Percutaneous Coronary Intervention

Aims: To identify risk factors for cardiac death of elderly and severe chronic kidney disease (CKD) patients with coronary atherosclerotic heart disease (CAHD) after percutaneous coronary intervention (PCI). Methods: 1010 CAHD-CKD patients over 60 years old who had CKD stage 3 or above and underwent PCI were followed up for at least 3 years. Cases of cardiac death were divided into groups. After univariate analysis of all variables, the variables with P < .2 were selected for further logistic regression. Results: For logistic regression single-vessel disease (SVD) PCI OR = 0.612, 95%CI: 0.416-0.899, P = .012, it is the protective factor. There are four risk factors, stable angina pectoris (SAP) OR = 4.723, 95%CI: 1.098∼20.322, P = .037, combined with lower extremity arteriosclerosis obliterans (LEASO) OR = 2.631, 95%CI: 1.272∼5.440, P = .009, K > 4.285 mmol/L OR = 1.44, 95%CI: 1.002∼2.069, P = .049, without statins OR = 2.015, 95%CI: 1.072∼3.789, P = .030. Conclusion: In elderly and serious CAHD-CKD patients after PCI, SVD PCI was a protective factor against cardiac death. However, SAP, CAHD-CKD combined with LEASO, K > 4.285 mmol/L, and no statins were independent risk factors of cardiac death for elderly patients with severe CKD after PCI.

Antithrombotic Therapy for Chronic Kidney Disease Patients With Concomitant Atrial Fibrillation and Coronary Artery Disease

Background: Oral anticoagulants (OAC) plus antiplatelets is recommended for patients with atrial fibrillation (AF) and coronary artery disease (CAD) to reduce thromboembolism. However, there is limited evidence regarding antithrombotic therapy for patients with concomitant chronic kidney disease (CKD), AF, and CAD, especially those not undergoing percutaneous coronary intervention. We aimed to use real-world data assessing the efficacy and safety of antithrombotic regimens in this population.

Methods: We used a single-center database of 142,624 CKD patients to identify those receiving antithrombotic therapy for AF and CAD between 2010 and 2018. Patients taking warfarin or direct OAC (DOAC) alone were grouped in the OAC monotherapy (n = 537), whereas those taking OAC plus antiplatelets were grouped in the combination therapy (n = 2,391). We conducted propensity score matching to balance baseline covariates. The endpoints were all-cause mortality, major adverse cardiovascular events, and major bleedings.

Results: After 1:4 matching, the number of patients in OAC monotherapy and combination therapy were 413 and 1,652, respectively. Between the two groups, combination therapy was associated with higher risks for ischemic stroke (HR 2.37, CI 1.72–3.27), acute myocardial infarction (HR 6.14, CI 2.51–15.0), and hemorrhagic stroke (HR 3.57, CI 1.35–9.81). The results were consistent across CKD stages. In monotherapy, DOAC users were associated with lower risks for all-cause mortality, AMI, and gastrointestinal bleeding than warfarin, but the stroke risk was similar between the two subgroups.

Conclusions: For patients with concomitant CKD, AF and CAD not undergoing PCI, OAC monotherapy may reduce stroke and AMI risks. DOAC showed more favorable outcomes than warfarin.

Dosing of losartan in men versus women with heart failure with reduced ejection fraction: the HEAAL trial

AIMS

In heart failure with reduced ejection fraction (HFrEF), guidelines recommend up-titration of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptors blockers (ARBs) to the maximum tolerated dose. However, some studies suggest that women might need lower doses of ACEi/ARBs than men to achieve similar treatment benefit.

METHODS AND RESULTS

The HEAAL trial compared low vs. high dose of losartan. We reassessed the efficacy and safety of high- vs. low-dose in men vs. women using Cox models and machine learning algorithms. The mean age was 66 years and 30% of patients were women. Men appeared to have benefited more from high-dose than from low-dose losartan, whereas women appeared to have responded similarly to low and high doses [hazard ratio (95% confidence interval) comparing high- vs. low-dose losartan for the composite outcome of all-cause death or all-cause hospitalization: 0.89 (0.81-0.98) in men and 1.10 (0.95-1.28) in women; interaction P = 0.018]. Female sex clustered along with older age, ischaemic heart failure, New York Heart Association class III/IV, and estimated glomerular filtration rate <60 mL/min. Patients with these features had a poorer response to high-dose losartan. Subgroup analyses supported no benefit from high-dose losartan in patients with poorer kidney function and severe heart failure symptoms.

CONCLUSIONS

Compared with men, women might need lower doses of losartan to achieve similar treatment benefit. However, beyond sex, other factors (e.g. kidney function, age, and symptoms) may influence the response to high-dose losartan, suggesting that sex-based subgroup findings may be biased by other confounders.

The Relationship Between Chronic Kidney Disease and the Severity and Long-Term Prognosis of Patients with Coronary Artery Disease After Drug-Eluting Stent Implantation

Objective

To investigate the relationship between chronic kidney disease (CKD) and the severity and long-term prognosis of patients with coronary artery disease (CAD) after drug-eluting stent (DES) implantation.

Methods

There were 814 patients, who consecutively received a DES implantation, selected for this study. They were divided into two groups, according to whether or not they suffered CKD. There were 254 cases in the CKD group (31.2%), while there were 560 cases (68.8%) in the control group. The clinical characteristics, coronary artery lesions, and major adverse cardiac and cerebrovascular events (MACCE) of the two groups were compared, and the relationship between risk factors and MACCEs was analyzed by multivariate logistic regression.

Results

Compared with the control group, the CKD group had more severe coronary artery stenosis, expressed as the more diseased arteries (2.15 ± 0.82 vs 1.87 ± 0.83, p = 0.001), a high incidence of three diseased arteries (42.0% vs 28.3%, p = 0.001), and a higher Gensini score [37 (18.6, 66) vs 27.5 (12, 52.5), p = 0.009]. The one-year post-implant incidence of MACCE was higher in the CKD group compared with the control group (17.6% vs 9.9%, p = 0.006).

Conclusion

CKD appears to be an important predictor for the prognosis of CAD.

Attainment of Guideline-Directed Medical Treatment in Stable Ischemic Heart Disease Patients With and Without Chronic Kidney Disease

BACKGROUND

Stable ischemic heart disease (SIHD) is prevalent in patients with chronic kidney disease (CKD); however, whether guideline-directed medical therapy (GDMT) is adequately implemented in patients with SIHD and CKD is unknown.

HYPOTHESIS

Use of GDMT and achievement of treatment targets would be higher in SIHD patients without CKD than in patients with CKD.

METHODS

This was a retrospective study of 563 consecutive patients with SIHD (mean age 67.8 years, 84% Caucasians, 40% females). CKD was defined as an estimated glomerular filtration rate (eGFR) of < 60 mL/min/1.73m² using the four-variable MDRD Study equation. We examined the likelihood of achieving GDMT targets (prescription of high-intensity statins, antiplatelet agents, renin-angiotensin-aldosterone system inhibitors (RAASi), and low-density lipoprotein cholesterol levels < 70 mg/dL, blood pressure < 140/90 mmHg, and hemoglobin A1C < 7% if diabetes) in patients with (n = 166) and without CKD (n = 397).

RESULTS

Compared with the non-CKD group, CKD patients were significantly older (72 vs 66 years; p < 0.001), more commonly female (49 vs 36%; p = 0.002), had a higher prevalence of diabetes (46 vs 34%; p = 0.004), and left ventricular systolic ejection fraction (LVEF) < 40% (23 vs. 10%, p < 0.001). All GDMT goals were achieved in 26% and 24% of patients with and without CKD, respectively (p = 0.712). There were no between-group differences in achieving individual GDMT goals with the exception of RAASi (CKD vs non-CKD: adjusted risk ratio 0.73, 95% CI 0.62-0.87; p < 0.001).

CONCLUSIONS

Attainment of GDMT goals in SIHD patients with CKD was similar to patients without CKD, with the exception of lower rates of RAASi use in the CKD group.

Effects of Danshen tablets on pharmacokinetics of amlodipine in rats

CONTEXT

Danshen tablets (DST), an effective traditional Chinese multi-herbal formula, are often combined with amlodipine (ALDP) for treating coronary heart disease.

OBJECTIVE

This study investigated the effects of DST on the pharmacokinetics of ALDP and the potential mechanism.

MATERIALS AND METHODS

The pharmacokinetics of ALDP (1 mg/kg) in male Sprague-Dawley rats (n = 6), with or without pretreatment of DST (100 mg/kg for 7 d), were investigated using LC-MS/MS. The effects of DST on the metabolic stability of ALDP were also investigated using rat liver microsomes (RLM).

RESULTS

The results indicated that C_max (16.25 ± 2.65 vs. 22.79 ± 2.35 ng/ml), AUC_(0-t) (222.87 ± 59.95 vs. 468.32 ± 69.87 n gh/ml), and t_1/2 (10.60 ± 1.05 vs. 14.15 ± 1.59 h) decreased significantly when DST and ALDP were co-administered, which suggested that DST might influence the pharmacokinetic behaviour of ALDP when they are co-administered. The metabolic stability of ALDP was also decreased (23.6 ± 4.7 vs. 38.9 ± 5.2) with the pretreatment of DST.

DISCUSSION AND CONCLUSIONS

This study indicated that DST could accelerate the metabolism of ALDP in RLM and change the pharmacokinetic behaviours of ALDP. Accordingly, these results showed that the herb-drug interaction between DST and ALDP might occur when they were co-administered. Therefore, the clinical dose of ALDP should be increased when DST and ALDP are co-administered.

Impact of age on cardiovascular drug use in patients with chronic kidney disease

Background

Elderly patients with chronic kidney disease (CKD) are often excluded from clinical trials; this may affect their use of essential drugs for cardiovascular complications. We sought to assess the impact of age on cardiovascular drug use in elderly patients with CKD.

Methods

We used baseline data from the Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort including 3033 adult patients with CKD Stages 3 and 4. We studied the use of recommended drugs for coronary artery disease (CAD), stroke and atrial fibrillation by age, after adjusting for socio-demographic and clinical conditions.

Results

The patients’ mean age was 66.8 years (mean estimated glomerular filtration rate 32.9 mL/min/1.73 m²). The prevalence of CAD was 24.5% [81.3% receiving antiplatelet agents, 75.6% renin–angiotensin system (RAS) blockers, 65.4% β-blockers and 81.3% lipid-lowering therapy], that of stroke 10.0% (88.8% receiving antithrombotic drugs) and that of atrial fibrillation 11.1% (69.5% receiving oral anticoagulants). Compared with patients aged <65 years, older age (≥65 years) was associated with greater use of antithrombotic drugs in stroke [adjusted odds ratio (aOR) (95% confidence interval) = 2.83 (1.04–7.73) for patients aged (75–84 years)] and less use of RAS blockers [aOR = 0.39 (0.16–0.89) for patients aged ≥85 years], β-blockers [aOR = 0.31 (0.19–0.53) for patients aged 75–84 years] and lipid-lowering therapy [aOR = 0.39 (0.15–1.02) for patients aged ≥85 years, P for trend = 0.01] in CAD. Older age was not associated with less use of antiplatelet agents in CAD or oral anticoagulants in atrial fibrillation.

Conclusions

In patients with CKD, older age per se was not associated with the underuse of antithrombotic drugs but was for other major drugs, with a potential impact on cardiovascular outcomes.

Single dose oral ranolazine pharmacokinetics in patients receiving maintenance hemodialysis

Purpose: Ranolazine is a novel anti-angina treatment approved in the United States for chronic stable angina. Ranolazine pharmacokinetics have not been studied previously in patients who receive maintenance hemodialysis. This study describes the pharmacokinetics of ranolazine and three major metabolites (CVT-2738, CVT-2512, CVT-2514) in patients receiving thrice weekly hemodialysis.

Methods: Eight participants receiving maintenance hemodialysis completed this prospective, open-label study (study identifier NCT01435174 at Clinicaltrials.gov). Three participants received a single tablet of ranolazine 500 mg (followed by an interim analysis), and five received 2 tablets of ranolazine 500 mg. Blood samples were collected over 65 h to determine the pharmacokinetic characteristics during and between hemodialysis sessions. Non-compartmental analysis was used to determine the individual pharmacokinetic parameters.

Results: Ranolazine off-hemodialysis elimination phase half-lives were 3.6 and 3.9 h for 500 mg and 1000 mg doses, respectively. The time to maximum concentration ranged from 2 to 18 hours and the average maximum concentration was 0.65 ± 0.27 mcg/mL and 1.18 ± 0.48 mcg/mL for ranolazine 500 mg and 1000 mg dose, respectively. The mean hemodialysis percent reduction ratio for the ranolazine 500 mg dose was 52.3 ± 8.1% and for the ranolazine 1000 mg dose was 69.2 ± 37.6%.

Conclusions: Data on ranolazine dosing in patients receiving maintenance hemodialysis is almost non-existent. Given the extent of pharmacokinetic variability observed with the 500 mg and 1000 mg oral doses of ranolazine, neither can be recommended as a starting dose in patients receiving maintenance hemodialysis. Guided by the information gained form this study about the extent of hemodialytic drug clearance, further multi-dose clinical trials of ranolazine are needed to optimize therapeutic outcomes in this patient population.

Analysis of clinical pharmacist interventions in the neurology unit of a Brazilian tertiary teaching hospital

It is estimated that around five to 10.0% of hospital admissions occur due to clinical conditions resulting from pharmacotherapy. Clinical pharmacist's activity can enhance drug therapy's effectiveness and safety through pharmacotherapy interventions (PIs), thus minimizing drug-related problems (DRPs) and optimizing the allocation of financial resources associated with health care. This study aimed to estimate the DRPs prevalence, evaluate PI which were performed by clinical pharmacists in the Neurology Unit of a Brazilian tertiary teaching hospital and to identify factors associated with the occurrence of PI-related DRP. A single-arm trial included adults admitted in the referred Unit from 2012 July to 2015 June. Patients were evaluated during their hospitalization period and PIs were performed based on trigger DRPs that were detected in medication reconciliation (admission or discharge) or during inpatient follow-up. Student's t-test, Chi-square test, Pearson and Multiple logistic regression models to analise the association among age, number of drugs, hospitalization period, and number of diagnoses with occurrence of DRPs. Analyses level of significance was 5%. In total 409 inpatients were followed up [51.1% male, mean age of 49.1 (SD 16.5)]. Patients received, on average, 11.9 (SD 5.8) drugs, ranging from two to 38 drugs per patient, and 54.3% of the sample presented at least one DRP whose most frequent description was "untreated condition". From all 516 performed PIs that resulted from DRPs, 82.8% were accepted and the majority referred to "drug introduction" (27.5%). Multiple logistic regression showed that age, length of hospital stay, number of drugs used, diagnosis of epilepsy, multiple sclerosis and myasthenia gravis would be clinical variables associated with DRP (p < 0,05). Monitoring the use of drugs allowed the clinical pharmacist to detect DRPs and to suggest interventions that promote rational pharmacotherapy.

Effects of triptolide on pharmacokinetics of amlodipine in rats by using LC-MS/MS

CONTEXT

Triptolide and amlodipine are often simultaneously used for reducing urine protein excretion after renal transplantation in China clinics.

OBJECTIVE

This study investigated the effects of triptolide on the pharmacokinetics of amlodipine in male Sprague-Dawley rats.

MATERIALS AND METHODS

The pharmacokinetics of amlodipine (1 mg/kg) with or without triptolide pre-treatment (2 mg/kg/day for seven days) were investigated using a sensitive and reliable LC-MS/MS method. Additionally, the inhibitory effects of triptolide on the metabolic stability of amlodipine were investigated using rat liver microsome incubation systems.

RESULTS

The results indicated that when the rats were pre-treated with triptolide, the Cmax of amlodipine increased from 13.78 ± 3.57 to 19.96 ± 4.56 ng/mL (p < 0.05), the Tmax increased from 4.04 ± 1.15 to 5.89 ± 1.64 h (p < 0.05), and the AUC0-t increased by approximately 104% (p < 0.05), which suggested that the pharmacokinetic behaviour of amlodipine was affected after oral co-administration of triptolide. Additionally, the metabolic half-life was prolonged from 22.5 ± 4.26 to 36.8 ± 6.37 min (p < 0.05) with the pre-treatment of triptolide.

CONCLUSIONS

In conclusion, these results indicated that triptolide could affect the pharmacokinetics of amlodipine, possibly by inhibiting the metabolism of amlodipine in rat liver when they are co-administered.

Effect Of epigallocatechin-3-gallate on the pharmacokinetics of amlodipine in rats

This study investigates the effect of epigallocatechin-3-gallate (EGCG), a major ingredient of green tea, on the pharmacokinetics of amlodipine in rats. The pharmacokinetics of orally administered amlodipine (1 mg/kg) with or without EGCG pretreatment (30 mg/kg/day for 10 days) were investigated. Plasma concentrations of amlodipine were determined by using a sensitive and reliable liquid chromatography with tandem mass spectroscopy (LC-MS/MS) method. The effects of EGCG on the metabolic stability of amlodipine were investigated by using rat liver microsome incubation systems. The results indicated that when the rats were pretreated with EGCG, the C_max of amlodipine increased from 16.32 ± 2.57 to 21.44 ± 3.56 ng/mL (p < 0.05), the T_max decreased from 5.98 ± 1.25 to 4.01 ± 1.02 h (p < 0.05), and the AUC_0-t increased from 258.12 ± 76.25 to 383.34 ± 86.95 μg h L^-1 (p < 0.05), which suggested that the pharmacokinetic behavior of amlodipine was affected after oral co-administration of EGCG. Additionally, the metabolic half-life was prolonged from 31.3 ± 5.6 to 52.6 ± 7.9 min (p < 0.05) with the pretreatment of EGCG. It can be speculated that the drug-drug interaction between EGCG and amlodipine might occur, which might have resulted from the metabolism inhibition of amlodipine by EGCG when they were co-administered.

Water exercise in coronary artery disease patients, effects on heart rate variability, and body composition: A randomized controlled trial

BACKGROUND AND PURPOSE

It is important to assess the effectiveness and efficiency of water-based training programs in order to prescribe it as an alternative in cardiac rehabilitation for patients who have coronary artery disease (CAD). In these patients, autonomic dysfunction is an important physiological change strongly associated with adverse outcomes, morbidity, and mortality. Given that the beneficial effects of physical training in CAD patients have been traditionally evidenced with programs involving land-based aerobic exercises, this study aims to evaluate the effects of water aerobic exercise training (WAET) on the autonomic modulation of heart rate (HR) and body composition, in the rehabilitation of CAD patients.

METHODS

Twenty-six male subjects with CAD were randomly divided into a training group (n = 14), submitted to the WAET, and a control group (n = 12). The WAET consisted of 3 weekly sessions on alternate days, totalling 48 sessions. The analysis of HR variability was used to evaluate the autonomic modulation of HR, from the recording of R-R intervals for 15 min, at rest in the supine position, and the body composition was evaluated through the bioelectrical impedance analysis.

RESULTS

Only the training group participants had improvement in the HR variability indices; patterns without variation decreased (0V, p = .005) and an increase of patterns of two different variations (p < .001), Shannon entropy (p = .02), and normalized conditional entropy (p = .03), whereas the control group had an increase of 0V (p = .04) and a decrease of normalized conditional entropy (p = .01). All body composition variables remained unchanged.

CONCLUSIONS

The WAET protocol improved the cardiac autonomic modulation of patients with CAD and can be considered as exercise training strategy in cardiac rehabilitation programs.

Effect of Ginkgo Leaf Tablets on the Pharmacokinetics of Amlodipine in Rats

BACKGROUND AND OBJECTIVE

Ginkgo leaf tablet (GLT) is an effective traditional Chinese multi-herbal formula, which is often combined with amlodipine for treating senile hypertension in clinic. The aim of this study was to study the pharmacokinetics of amlodipine after oral administration of amlodipine and GLT and to investigate the potential for pharmacokinetic herb-drug interactions between GLT and amlodipine in rats.

METHODS

A liquid chromatography-tandem mass spectrometry (LC-MS/MS) analytical method was developed for quantification of amlodipine in rat plasma. The accuracy, precision, linearity, selectivity and recovery were all within an acceptable range. Male Sprague-Dawley rats were randomly assigned to two groups: amlodipine group and amlodipine + GLT group. Plasma concentrations of amlodipine were determined at the designated time points after oral administration by using the developed LC-MS/MS method, and the main pharmacokinetic parameters were calculated and compared. As ginkgolides A, ginkgolides B, bilobalide, quercetin and kaempferol were the main components of GLT, the effects of these ingredients in GLT on metabolism of amlodipine were further investigated in rat liver microsomes.

RESULTS

The pharmacokinetic parameters, maximum plasma concentration (C _max), time to reach C _max (T _max), area under the concentration-time curve (AUC), area under the first moment plasma concentration-time curve (AUMC) and elimination half-life (t _1/2), of amlodipine were significantly increased in amlodipine + GLT group, which suggested that GLT may influence the pharmacokinetic behavior after oral co-administration with amlodipine. Amlodipine is metabolized by cytochrome P450 (CYP) 3A4, so it was speculated that GLT may change the pharmacokinetic parameters of amlodipine through modulating the metabolism of CYP3A4 enzymes. When ginkgolides B, bilobalide, or quercetin and amlodipine were co-incubated in the rat liver microsomes, the metabolic rate of amlodipine was prolonged to 533.1, 216.1 and 407.6 min, respectively, from 73.7 min.

CONCLUSIONS

These results suggested that these components in GLT inhibit the metabolism of amlodipine. So it can be speculated that the herb-drug interactions between GLT and amlodipine resulted from inhibiting the metabolism of amlodipine by GLT when they were co-administered.

Effect of Dialysis on Antiplatelet Drug Efficacy in Uremic Patients with Coronary Heart Disease

Background:

Coronary intervention therapy is the main treatment for uremic patients with coronary heart disease. The studies on whether dialysis reduces the efficacy of dual antiplatelet drugs are limited. The aim of this study was to examine the effect of dialysis on antiplatelet drugs in uremic patients with coronary heart disease.

Methods:

This study included 26 uremic patients who had undergone percutaneous coronary intervention in China-Japan Friendship Hospital from November 2015 to May 2017. We examined their thromboelastography results before and after hemodialysis. Self-paired t-tests were employed to analyze changes in the inhibition rate of platelet aggregation.

Results:

The mean inhibition rates of arachidonic acid-induced platelet aggregation before and after hemodialysis were 82.56 ± 2.79% and 86.42 ± 3.32%, respectively (t = −1.278, P = 0.213). The mean inhibition rates of adenosine diphosphate-induced platelet aggregation before and after hemodialysis were 67.87 ± 5.10% and 61.94 ± 5.90%, respectively (t = 1.425, P = 0.167). There was no significant difference in the inhibition rates of platelet aggregation before or after hemodialysis. These results also applied to patients with different sensitivity to aspirin and clopidogrel.

Conclusion:

Dialysis did not affect the antiplatelet effects of aspirin and clopidogrel in uremic patients with coronary heart disease.

Recent Trends in Management and Inhospital Outcomes of Acute Myocardial Infarction in Renal Transplant Recipients

Renal transplant recipients (RTR) are at high risk of cardiovascular events including acute myocardial infarction (AMI). We evaluated recent trends in AMI admissions in 9,243 RTR with functioning grafts using data from the 2003 to 2011 Nationwide Inpatient Sample database. Findings were compared with those of patients with end-stage renal disease without transplantation (ESRD-NRT, n = 160,932) and those without advanced kidney disease (non-ESRD/RT, n = 5,640,851) admitted with AMI. RTR comprised 0.2% of AMI admissions with increasing numbers during the study period (adjusted odds ratio [aOR] 1.04; 95% confidence interval [CI] 1.04 to 1.05; p_trend <0.001). Overall, 29.3% of admissions in RTR were for acute ST-segment elevation myocardial infarction (STEMI). Compared with non-ESRD/RT, history of renal transplantation was independently associated with a decreased likelihood of STEMI at presentation (aOR 0.73; 95% CI 0.65 to 0.80; p <0.001). Inhospital mortality among RTR admitted for NSTEMI decreased from 3.8% in 2003 to 2.1% in 2011 (aOR 0.85; 95% CI 0.78 to 0.93; p <0.001), whereas that for STEMI remained unchanged (7.6% in 2003; 9.3% in 2011, aOR 0.97; 95% CI 0.90 to 1.03; p = 0.36). Rates of percutaneous coronary interventions were higher, and inhospital mortality was lower among RTR compared with ESRD-NRT (p <0.001 for both). Treatment strategies appeared largely unchanged during the course of this study with the exception of an increase in primary percutaneous coronary intervention among RTR admitted with STEMI. In conclusion, RTR were frequently admitted with AMI, particularly NSTEMI, and were found to have multiple coronary artery disease risk factors despite their younger age. Compared with other forms of renal replacement therapy, renal transplant was associated with lower inhospital mortality.

Platelets in liver and renal disease

This review will discuss how 2 common and morbid conditions, renal disease and liver disease, alter platelet number and function. It will review the impact of thrombocytopenia on bleeding complications in patients with these disorders and whether the low platelet count actually correlates with bleeding risk. Emerging data also suggest that platelets are much more than bystanders in both renal and liver disease, but instead play an active role in the pathobiology of these disorders. This review will briefly cover the emerging information on novel roles of platelets in the biology of renal and liver disease.

Long-Term Renal Function after Endovascular Aneurysm Repair

BACKGROUND AND OBJECTIVES

Endovascular repair (EVAR) is a common treatment for abdominal aortic aneurysm (AAA). However, its long-term effects on renal function remain unclear. We aimed to assess long-term renal dysfunction after EVAR using a contemporary estimate of GFR and to compare long-term renal outcomes in patients after EVAR with open aneurysm repair (OAR) and in patients without an AAA.

DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS

We performed a nested case-matched analysis of 726 patients (using a prospectively maintained database for repairs that took place between January 2000 and May 2010 in a tertiary center): 121 patients undergoing OAR (with data at baseline and 5 years postrepair) were case matched (age, sex, smoking, diabetes, baseline eGFR) to patients undergoing suprarenal and infrarenal fixation EVAR (242 in each group) and to 121 patients undergoing carotid endarterectomy (CEA) without AAA. Changes in eGFR were compared (1 and 5 years).

RESULTS

The OAR patients lost an average of 7.4 ml/min per 1.73 m2 at 5 years (95% confidence interval [95% CI], 4.8 to 10.6), compared with 8.2 ml/min per 1.73 m2 (95% CI, 6.5 to 10.8; P<0.001) for infrarenal-fixation EVAR, 16.9 ml/min per 1.73 m2 (95% CI, 13.0 to 21.9, P<0.001) for suprarenal-fixation EVAR, and 5.4 ml/min per 1.73 m2 (95% CI, 1.7 to 7.5; P<0.001) for CEA. The decrease in eGFR was steeper during the first postoperative year, with each group losing -2.2 ml/min per 1.73 m2 (infrarenal-fixation EVAR), -10.7 ml/min per 1.73 m2 (suprarenal-fixation EVAR), and -4.6 ml/min per 1.73 m2 (OAR), compared with -1.9 ml/min per 1.73 m2 for CEA.

CONCLUSIONS

Elective EVAR is associated with a significant decline in eGFR after 5 years, which is steeper in the first postoperative year and more pronounced compared with a similar population with atherosclerotic disease.

Atenolol Renal Secretion Is Mediated by Human Organic Cation Transporter 2 and Multidrug and Toxin Extrusion Proteins

Atenolol is a β-blocker widely used in the treatment of hypertension. Atenolol is cleared predominantly by the kidney by both glomerular filtration and active secretion, but the molecular mechanisms involved in its renal secretion are unclear. Using a panel of human embryonic kidney cell lines stably expressing human organic cation transporter (hOCT) 1-3, human organic anion transporter (hOAT) 1, hOAT3, human multidrug and toxin extrusion protein (hMATE) 1, and hMATE2-K, we found that atenolol interacted with both organic cation and anion transporters. However, it is transported by hOCT1, hOCT2, hMATE1, and hMATE2-K, but not by hOCT3, hOAT1, and hOAT3. A detailed kinetic analysis coupled with absolute quantification of membrane transporter proteins by liquid chromatography-tandem mass spectrometry revealed that atenolol is an excellent substrate for the renal transporters hOCT2, hMATE1, and hMATE2-K. The Km values for hOCT2, hMATE1, and hMATE2-K are 280 ± 4, 32 ± 5, and 76 ± 14 μM, respectively, and the calculated turnover numbers are 2.76, 0.41, and 2.20 s(-1), respectively. To demonstrate unidirectional transepithelial transport of atenolol, we developed and functionally validated a hOCT2/hMATE1 double-transfected Madin-Darby canine kidney cell culture model. Transwell studies showed that atenolol transport in the basal (B)-to-apical (A) direction is 27-fold higher than in the A-to-B direction, whereas its B-to-A/A-to-B transport ratio was only 2 in the vector-transfected control cells. The overall permeability of atenolol in the B-to-A direction in hOCT2/hMATE1 cells was 44-fold higher than in control cells. Together, our data support that atenolol tubular secretion is mediated through the hOCT2/hMATEs secretion pathway and suggest a significant role of organic cation transporters in the disposition of an important antihypertensive drug.