P222 BENEFITS OF IVRABRADINE IN HEART FAILURE: FROM TRIALS TO CLINICAL PRACTICE

 

The incidence and prevalence of heart failure (HF) are constantly increasing and represent a fundamental problem for patient hospitalizations and the resulting healthcare costs. In the latest European guidelines the importance of therapeutic optimization in patients suffering from (SCC) has been emphasized to improve prognosis. This was confirmed by the results of the SHIFT trial, aimed at establishing the efficacy of Ivabradine in addition to therapy for the SC. The SHIFT study was performed in symptomatic HF patients with left ventricular systolic dysfunction. Patients were in NYHA class between II and IV and with at least one HF exacerbation hospitalization in the previous year, were randomized to receive Ivabradine at an initial dose of 5 mg twice a day. All patients were treated at the optimal dose of therapy, with ACE–I or Sartani (90%), BB (90%) and MRA (60%). The average follow–up was 24 months. Patients who received ivabradine showed a significant 20% reduction in hospitalization for heart failure exacerbation. These results were also confirmed by the improvement of the clinical picture based on the NYHA classification and the ejection fraction. Also in our clinical practice we found the same result: 6 patients of average age (70–75 years), suffering from HF with severe left ventricular systolic dysfunction (NHYA III), and arterial hypertension in standard therapy optimal for HF according to LG, reach outpatient evaluation for clinical and instrumental follow–up. On check–up, they have dilated heart disease with severe left ventricular systolic dysfunction (FE 35–38%) on the echocardiogram. Therapy with Ivabradine 5 mg x 2 / day was introduced. Upon clinical re–evaluation, after 6 months of therapy, an improvement in the functional class of SC (from NYHA III to NYHA II) and in the ejection fraction (from 38% to 45%) was noted.

Conclusions

Ivabradine, together with optimal medical therapy for HF, reduced hospitalizations for HF, increased survival and improved patient symptoms, reducing left ventricular remodeling, as confirmed by our clinical practice. Therefore, therapy with Ivabradine, in combination with Beta–Blockers or alone, constitutes a rational and synergistic therapeutic choice for improving the prognosis and quality of life in patients with SCC.

P184 DIASTOLIC FUNCTION IN PATIENTS WITH HEART FAILURE AND REDUCED EJECTION FRACTION TREATED BY SACUBITRIL/VALSARTAN

Background

After the remarkable success of the PARADIGM.HF trial, SAC/VAL was approved by European Society of Cardiology (ESC2016) and the American Heart Association (AHA2017), for the treatment of adults with chronic heart failure with reduced ejection fraction (HFrEF) (NYHA class II–IV), to reduce the risk of cardiovascular death and hospitalization. CurrentlySAC/VAL is recommended in patients with a left ventricular ejection fraction (LVEF) <35% as a replacement for an ACEI or ARB to further reduce the risk of HF hospitalization and death in ambulatory patients who remain symptomatic despite optimal treatment with an ACE–I, a beta–blocker and an MRA. However, the real world HF population differ from patients in randomized controlled trials in many clinical aspects. AIM: The aim of our work was to evaluate the reversibility of diastolic dysfunction before and after sacubitril/valsartan administration in patients with HF REF.

Methods

A total of 30 patients in NYHA class II–III and treated by ACE inhibitor or AAR2, were prospectively commenced on SAC/VAL (one tablet 24/26 mg twice daily). To classify diastolic dysfunction according to the ASE/EACVI guidelines published in 2016, transmitral E and A waves velocities, septal and lateral E’ tissue velocities, indexed left atrium volume and peak velocity of tricuspid regurgitation were collected. From multiparametric approach, Patients were subsequently categorized as diastolic dysfunction grade 1, 2 or 3.

Results

Mean age was 64.5±15 yo and 74 % patients were males. Ejection fraction averaged 35.5±7.0. Overall, after 12±3.0 months of treatment with sacubitril/valsartan, E/A ratio decreased from 1.9±1.5 to 1.04±0.72 (P < 0.05), the E/Ea ratio decreased from 14±6.0 vs. 09.5±5.0 (P < 0.05), tricuspid regurgitation peak velocity decreased from 3.0±0.7 to 2.4 m/s (P = 0.03) and left atrial volume decreased from 51.3±27.5 to 40.4±13.7ml/m2 (P < 0.05). Subsequently, both left–ventricular diastolic function and filling pressure improved significantly (P < 0.05, ).

Conclusions

In patients with HFrEF, administration of sacubitril/valsartan was associated with improvement of diastolic dysfunction and filling pressure, as shown in many studies.

P190 CAROTID DOPPLER ULTRASONOGRAPHIC AND DAPAGLIFOZIN IN TYPE 2 DIABETIC PATIENTS

Background

Carotid Doppler ultrasonography (USG) is widely used to measure haemodynamic parameters, such as Intima–Media Thickness (IMT) and blood flow velocities (i.e. Peak–Systolic Velocity [PSV], End–Diastolic Velocity [EDV], and Resistive Index [RI]). Dapaglifozin (SGLT2i) have been shown to reduce the risk of cardiovascular disease in type 2 diabetes (T2DM) patients. SGLT2i is a sodium–glucose co–transporter 2 inhibitor that reduces renal glucose reabsorption, thus increasing urinary glucose excretion. This leads to sustained systolic and diastolic blood pressure reduction, through natriuresis. We hypothesized that this agent would also reduce arterial stiffness.

Aim

The purpose of this study was to evaluate cardiovascular disease risk indirectly through USG of carotid artery vascular markers in T2DM patients using dapagliflozin.

Methods and Results

40 patients presenting to our clinic between march 2019 and march 2021 and diagnosed with T2DM were included in the study. These were divided into two groups : 1) a dapagliflozin group of 20 patients and 2) 20 patients non–dapagliflozin control group. Velocity parameters were: peak–systolic velocity (PSV), end–diastolic velocity (EDV), pulsatility index (PI), resistive index (RI). Examination was performed on distal portion of CCA, and we took the mean of both CCA. The mean duration of follow–up was 2.0 years. Mean ages were 55 ± 10 years in the dapagliflozin group and 50 ± 10 in the control group. Common carotid artery, PSV, and EDV parameters were higher while RI was lower (p ˂ 0.01), in the dapagliflozin group than in the control group. Vascular resistance was lower in the group using dapagliflozin for diabetes management. In addition In the dapagliflozin group, the IMT decreased after dapagliflozin therapy (P < 0.01).

Conclusions

haemodynamic parameters were better performing in the group using dapagliflozin for diabetes management. Finally SGLT2i can decrease the IMT in patients with T2DM, which is closely related to cardiovascular benefit in patients with T2DM.

The Procoagulant Activity of Emoxilane®: A New Appealing Therapeutic Use in Epistaxis of the Combination of Sodium Hyaluronate, Silver Salt, α-tocopherol and D-panthenol

Epistaxis is one of the most frequent hemorrhages resulting from local or systemic factors. Its management without hospitalization has prompted an interest in locally applied hemostatic agents. Generally, the therapy approaches involve sprays or creams acting as a physical barrier, even used as tampons or gauze. In this study, we have investigated the activity of Emoxilane^®, a combination of sodium hyaluronate, silver salt, α-tocopherol acetate and D-panthenol, which is known to be able to separately act in a different biological manner. Our in vitro results, obtained on endothelial and nasal epithelial cells, have shown that the association of these molecules presented a notable antioxidant activity mainly due to the α-tocopherol and D-panthenol and a significant antimicrobial role thanks to the silver compound. Moreover, remarkable hemostatic activity was found by evaluating plasmin inhibition attributable to the sodium hyaluronate. Interestingly, on human plasma, we have confirmed that Emoxilane^® strongly induced the increase of thrombin levels. These data suggest that the use of this association could represent an appealing pharmacological approach to actively induce hemostasis during epistaxis. Our future perspective will aim to the creation of a formulation for an easy topical application in the nose which is able to contrast the bleeding.

Pectin and Zinc Alginate: The Right Inner/Outer Polymer Combination for Core-Shell Drug Delivery Systems

Core-shell beads loaded with betamethasone were developed using co-axial prilling as production technique and pectin plus alginate as polymeric carriers. During this study, many operative conditions were intensively investigated to find the best ones necessary to produce uniform core-shell particle systems in a reproducible way. Particularly, feed solutions' composition, polymers mass ratios and the effect of the main process parameters on particles production, micromeritics, inner structure, drug loading and drug-release/swelling profiles in simulated biological fluids were studied. The optimized core-shell formulation F5 produced with a pectin core concentration of 4.0% w/v and an alginate shell concentration of 2.0% w/v (2:1 core:shell ratio) acted as a sustained drug delivery system. It was able to reduce the early release of the drug in the upper part of the gastro-intestinal tract for the presence of the zinc-alginate gastro-resistant outer layer and to specifically deliver it in the colon, thanks to the selectivity of amidated low methoxy pectin core for this district. Therefore, these particles may be proposed as colon targeted drug delivery systems useful for inflammatory bowel disease (IBD) therapy.

Synergistic effect of divalent cations in improving technological properties of cross-linked alginate beads

Gelling solution parameters are some of the most important variables in ionotropic gelation and consequently influence the technological characteristics of the product. To date, only a few studies have focused on the simultaneous use of multiple cations as gelling agents. With the aim to deeply explore this possibility, in this research we investigated the effect of two divalent cations (Ca²⁺ and Zn²⁺) on alginate beads formation and properties. Alginate beads containing prednisolone (P) as model drug were prepared by prilling technique. The main critical variables of the ionotropic gelation process i.e. composition of the aqueous feed solutions (sodium alginate and prednisolone concentration) and cross-linking conditions (Ca²⁺, Zn²⁺ or Ca²⁺+Zn²⁺), were studied. The obtained beads were characterized and their in vitro release performances were assessed in conditions simulating the gastrointestinal environment. Results evidenced a synergistic effect of the two cations, affecting positively both the encapsulation efficiency and the ability of the alginate polymeric matrix to control the drug release. A Ca²⁺/Zn²⁺ ratio of 4:1, in fact, exploited the Ca²⁺ ability of establish quicker electrostatic interactions with guluronic groups of alginate and the Zn²⁺ ability to establish covalent-like bonds with carboxylate groups of both guluronic and mannuronic moieties of alginate.

Prednisolone Delivery Platforms: Capsules and Beads Combination for a Right Timing Therapy

In this work, a platform of alginate beads loaded with Prednisolone in hypromellose/gellan gum capsules (F6/Cps) able to delay steroidal anti-inflammatory drug (SAID) release as needed for chronotherapy of rheumatoid arthritis is proposed. Rheumatoid arthritis, showing a worsening in symptoms in the morning upon waking, is a pathology that can benefit from chronotherapy. With the aim to maximize prednisolone therapeutic action allowing the right timing of glucocorticoid therapy, different engineered microparticles (gel-beads) were manufactured using prilling (laminar jet break-up) as micro-encapsulation technique and Zn-alginate as gastroresistant carrier. Starting from various feed solutions and process parameters, the effect of the variables on particles size, morphology, solid state properties and drug release was studied. The optimization of operative and prilling/ionotropic gelation variables led to microspheres with almost spherical shape and a narrow dimensional range. The feed solution with the highest alginate (2.5% w/v) amount and drug/polymer ratio (1:5 w/w) gave rise to the highest encapsulation efficiency (78.5%) as in F6 formulation. As to drug release, F6 exhibited an interesting dissolution profile, releasing about 24% of the drug in simulated gastric fluid followed by a more sustained profile in simulated intestinal fluid. #F6, acting as a gastro-resistant and delayed release formulation, was selected for in vivo studies on male Wistar rats by means of a carrageenan-induced oedema model. Finally, this efficacious formulation was used as core material for the development of a final dosage form: F6/Cps allowed to significantly reduce prednisolone release in simulated gastric fluid (12.6%) and delayed drug release up to about 390 minutes.

Freehand three-dimensional echocardiographic evaluation of the effect of telmisartan compared with hydrochlorothiazide on left ventricular mass in hypertensive patients with mild-to-moderate hypertension: a multicentre study

Antihypertensive efficacy, effects on left ventricular mass index (LVMI) and tolerability of telmisartan, an angiotensin II receptor blocker, were compared with those of hydrochlorothiazide (HCTZ). Adult patients with mild-to-moderate hypertension and an optimal acoustic window by two-dimensional echocardiography were randomised at baseline to 12 months' double-blind, once-daily treatment with telmisartan 80 mg or HCTZ 25 mg. Two-dimensional echocardiography and freehand precordial three-dimensional echocardiography and 24-h ambulatory blood pressure monitoring were performed at baseline and after treatment. Of the 41 telmisartan group patients and 28 HCTZ group patients, 40 and 25, respectively, completed the study. Following treatment, 24-h mean SBP (telmisartan 157 +/- 11 vs 133 +/- 7 mmHg, P<0.001; HCTZ 154 +/- 10 vs 144 +/- 11 mmHg, P<0.003) and DBP (telmisartan 96 +/- 6 vs 83 +/- 5 mmHg, P<0.001; HCTZ 95 +/- 7 vs 87 +/- 8 mmHg, P<0.003) were significantly reduced. Telmisartan produced significantly greater 24-h mean SBP and DBP reductions than HCTZ (P<0.001). LVMI was significantly reduced by telmisartan (141 +/- 16 vs 125 +/- 19 g/m2, P<0.001), but not by HCTZ (139 +/- 20 vs 135 +/- 22 g/m(2)). Incidences of adverse events in both the treatment groups were low; two cases of hypokalaemia occurred with HCTZ. In conclusion, telmisartan 80 mg was well tolerated and significantly reduced SBP, DBP and LVMI after 12 months' treatment compared with HCTZ.

[Prognostic value of the exertion test in patients treated with thrombolytic therapy for acute myocardial infarct]

Prognostic value of exercise testing after thrombolytic therapy in patients with acute myocardial infarction. Few studies have evaluated the prognostic value of exercise testing in patients suffering from acute myocardial infarction (AMI) and thrombolysis. For this reason the authors studies 398 patients divided into two groups: 189 thrombolysed patients (T) and 209 non-thrombolysed patients (NT), matched for age, sex, AMI site and treatment received. Thrombolysis was performed within 6 hours of the onset of symptoms using rt-PA in an accelerated regime (90 degrees) preceded by sodium heparin infusion 5000 UI i.v. in bolus, and followed by sodium heparin for 5 days, maintaining a PTT value 2-3 times the basal level. The efficacy of thrombolytic treatment was confirmed by the presence pf at least two of the following markers: CK peak time, rapid reduction of ST overunlevelling, reperfusion arrhythmia. All patients underwent exercise testing using the cycloergometer after suspending treatment at 3 weeks and 6 months after AMI, and a echocardiographic examination on the first day and after 6 months. These data show that thrombolytic treatment reduces the myocardial damage during the course of AMI, enabling the patient to exercise longer and causes improved myocardial contractility with a lower asynergic index compared to non-reperfused patients. Moreover, significantly fewer ergometric tests that were positive for residual ischemia were observed in T compared to NT. The incidence of mortality one year after AMI was low in both groups, albeit lower in T. This confirms the important prognostic role of ergometric tests also in this population.

[Changes in platelet production of malondialdehyde in diabetics treated with dilazep]

We have investigated the effect of dilazep on the prostaglandin synthesis determined as indicator malondialdehyde (MDA) formation. Twenty patients with type 2 diabetes, aged 25-65 years were orally given dilazep at 100 mg X 3/day for 56 daily. The platelet activity has valued before and after the treatment with the production of the MDA. We conclude that the dilazep inhibited statistically significant biosynthesis of prostaglandin endoperoxides from arachidonic acid.

[The effect of dilazep on circulating platelet aggregation in diabetics]

The aim of the present paper was to evaluate the effect of the 1,4 bis [3-(3,4,5-trimethoxybenzoyl-oxy) propyl] perhydro-1,4 diazepina (dilazep) on reduction of circulating platelet aggregates in 18 patients with type 2 diabetes, 13 female and 5 male, aged 25-65 years. Dilazep was orally given at 100 mg X 3/day for 8 weeks. The platelet activity has valued before and after the treatment trough the evaluation of circulating platelet aggregates with the method of Wu and Hoak. The results confirmed that the dilazep decreased statistically significant after 8 weeks the circulating aggregates.

Cortical control of neurally-mediated arrhythmogenic properties of desacetyl lanatoside C: the role of the posterior hypothalamus

Functional ablation of the cerebral cortex by cortical spreading depression (CSD) significantly increased the dose of desacetyl lanatoside C required to induce A-V block and ventricular fibrillation. To examine the role of the posterior hypothalamus in the increased resistance of decorticated rats to arrhythmia induced by toxic doses of desacetyl lanatoside C, four groups of animals were injected with this drug: group 1 rats had a craniotomy; group 2 rats had a craniotomy and functional decortication; group 3 rats had a craniotomy and a hypothalamic lesion; and group 4 rats had a craniotomy, hypothalamic lesion and functional decortication. The dose of drug required to induce A-V block and ventricular fibrillation was significantly less in group 1, than in groups 2,3 and 4, and there was no statistically significant difference between these last three groups. These results are consistent with the hypothesis that the increased resistance to arrhythmia induced by desacetyl lanatoside C in decorticated rats is mediated by the posterior hypothalamus.

[Effect of calcitonin on human gastric function]

The effects of calcitonin on the gastric secretion have been investigated. Five subjects (age 34 and approximately 70 kg on average) have been injected by 0,25 microgram/kg s.c. a decrease of gastric secretion has been detected. The inhibition of pepsin secretion is much larger than the effect on MAO and PAO. This supports the hypothesis that calcitonin inhibits protein synthesis of the gastric mucous.

[Cimetidine in experimental gastric ulcers induced by pyloric ligation]

Male albino rats of the Wistar strain, without food from 48 h, have been operated with pylorus ligature and treated with cimetidine, at the dose of 30 mg/kg i.m., just after the operation and 12 h later. Cimetidine reduced the size and the number of gastric ulcers induced by pylorus ligature, showing a significant protective effect. This action, due to the inhibition of gastric secretion induced by cimetidine, supports the hypothesis that the staunching of gastric juice (by pylorus ligature) plays a basic role in the pathogenesis of these experimental gastric ulcers.

[Cimetidine and the hypothalamo-hypophysial-suprarenal axis]

The effects of cimetidine on experimental stress, induced by a long time fast and pylorus ligature, in male albino rats were investigated. The drug at the dose of 30 mg/kg was administered i.m. just after the operation and 12 h later. To evaluate the interference of cimetidine on the hypothalamo-hypophyseal-adrenal axis were dosed, in the rat, the level of adrenal ascorbic acid and cholesterol as well as corticosterone plasma levels. The results seem to suggest that cimetidine, in this experiment, is unable to modify stress induced changes.