Natriuretic peptide system in hypertension: Current understandings of its regulation, targeted therapies and future challenges.

The natriuretic peptide system (NPS) is the key driving force of the heart's endocrine function. Recent developments in NPS-targeted therapies have been found promising and effective against cardiovascular diseases, including hypertension. Notably, after discovering crosstalk between NPS and the renin-angiotensin-aldosterone system (RAAS), various combinations such as neprilysin/angiotensin II receptor type 1 AT1 receptor inhibitors and neprilysin/renin inhibitors have been preclinically and clinically tested against various cardiac complications. However, the therapeutic effects of such combinations on the pathophysiology of hypertension are poorly understood. Furthermore, the complicated phenomena underlying NPS regulation and function, particularly in hypertension, are still unexplored. Mounting evidence suggests that numerous regulatory mechanisms modulate the expression of NPS, which can be used as potential targets against hypertension and other cardiovascular diseases. Therefore, this review will specifically focus on epigenetic and other regulators of NPS, identifying prospective regulators that might serve as new therapeutic targets for hypertension. More importantly, it will shed light on recent developments in NPS-targeted therapies, such as M-atrial peptides, and their latest combinations with RAAS modulators, such as S086 and sacubitril-aliskiren. These insights will aid in the development of effective therapies to break the vicious cycle of high blood pressure during hypertension, ultimately addressing the expanding global heart failure pandemic.

Plecanatide Improves Abdominal Bloating and Bowel Symptoms of Irritable Bowel Syndrome with Constipation.

BACKGROUND: Bloating is a bothersome symptom in irritable bowel syndrome with constipation (IBS-C). AIM: To evaluate plecanatide efficacy in patients with IBS-C stratified by bloating intensity. METHODS: Pooled phase 3 data (2 randomized, controlled IBS-C trials) from adults treated with plecanatide 3 mg or placebo for 12 weeks were analyzed. Patients were stratified post-hoc by baseline bloating severity (11-point scale: mild [≤ 5] and moderate-to-severe [> 5]). Assessments included change from baseline in bloating, abdominal pain, and complete spontaneous bowel movement (CSBM) frequency. Abdominal pain and bloating composite responders were defined as patients with ≥ 30% improvement from baseline in both bloating and abdominal pain at Week 12. RESULTS: At baseline, 1104/1436 patients with IBS-C (76.9%) reported moderate-to-severe bloating. In the moderate-to-severe bloating subgroup, plecanatide significantly reduced bloating severity versus placebo (least-squares mean change [LSMC]: - 1.7 vs - 1.3; P = 0.002), reduced abdominal pain (- 1.7 vs - 1.3; P = 0.006), and increased CSBM frequency (1.4 vs 0.8; P < 0.0001). In the mild bloating subgroup, significant improvements were observed with plecanatide versus placebo for abdominal pain (LSMC: - 1.3 vs - 1.0; P = 0.046) and CSBM frequency (2.0 vs 1.2; P = 0.003) but not bloating (- 0.9 vs - 0.8; P = 0.28). A significantly greater percentage of patients were abdominal pain and bloating composite responders with plecanatide versus placebo (moderate-to-severe bloating: 33.6% vs 26.8% [P = 0.02]; mild bloating: 38.4% vs 27.2% [P = 0.03]). CONCLUSION: Plecanatide treatment improved IBS-C abdominal and bowel symptoms, including in those who present with moderate-to-severe bloating.

Beyond Natriuretic Peptides: Unveiling the Power of Emerging Biomarkers in Heart Failure.

Heart failure (HF) represents a significant global health challenge, characterized by high morbidity and mortality rates, and imposes considerable burdens on healthcare systems and patient quality of life. Traditional management strategies, primarily relying on clinical assessments and standard biomarkers like natriuretic peptides, face limitations due to the heterogeneity of HF. This review aims to delve into the evolving landscape of non-natriuretic biomarkers and the transformative potential of omics technologies, underscoring their roles in advancing HF treatment towards precision medicine. By offering novel insights into the biological underpinnings of HF, including inflammation, myocardial stress, fibrosis, and metabolic disturbances, these advancements facilitate more accurate patient phenotyping and individualized treatment strategies. The integration of non-natriuretic biomarkers and omics technologies heralds a pivotal shift in HF management, enabling a move towards tailored therapeutic interventions. This approach promises to enhance clinical outcomes by improving diagnostic accuracy, risk stratification, and monitoring therapeutic responses. However, challenges such as the variability in biomarker levels, cost-effectiveness, and the standardization of biomarker testing across different healthcare settings pose hurdles to their widespread adoption. Despite these challenges, the promise of precision medicine in HF, driven by these innovative biomarkers and technologies, offers a new horizon for improving patient care and outcomes. This review advocates for the further integration of these advancements into clinical practice, highlighting the need for ongoing research to fully realize their potential in transforming the landscape of heart failure management.

Augmentation of natriuretic peptide (NP) receptor A and B (NPR-A and NPR-B) and cyclic guanosine monophosphate (cGMP) signalling as a therapeutic strategy in heart failure.

INTRODUCTION: Heart failure is a complex, debilitating condition and despite advances in treatment, it remains a significant cause of morbidity and mortality worldwide. Therefore, the need for alternative treatment strategies is essential. In this review, we explore the therapeutic strategies of augmenting natriuretic peptide receptors (NPR-A and NPR-B) and cyclic guanosine monophosphate (cGMP) in heart failure. AREAS COVERED: We aim to provide an overview of the evidence of preclinical and clinical studies on novel heart failure treatment strategies. Papers collected in this review have been filtered and screened following PubMed searches. This includes epigenetics, modulating enzyme activity in natriuretic peptide (NP) synthesis, gene therapy, modulation of downstream signaling by augmenting soluble guanylate cyclase (sGC) and phosphodiesterase (PDE) inhibition, nitrates, c-GMP-dependent protein kinase, synthetic and designer NP and RNA therapy. EXPERT OPINION: The novel treatment strategies mentioned above have shown great potential, however, large randomized controlled trials are still lacking. The biggest challenge is translating the results seen in preclinical trials into clinical trials. We recommend a multi-disciplinary team approach with cardiologists, geneticist, pharmacologists, bioengineers, researchers, regulators, and patients to improve heart failure outcomes. Future management can involve telemedicine, remote monitoring, and artificial intelligence to optimize patient care.

Plecanatide for the treatment of chronic idiopathic constipation and irritable bowel syndrome with constipation: Post hoc analyses of placebo-controlled trials in adults with severe constipation.

BACKGROUND: Patients with chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation (IBS-C) often experience severe symptoms. The current aim was to evaluate plecanatide in adults with CIC or IBS-C with severe constipation. METHODS: Data were analyzed post hoc from randomized, placebo-controlled trials (CIC [n = 2], IBS-C [n = 2]) of plecanatide 3 mg, 6 mg, or placebo administered for 12 weeks. Severe constipation was defined as no complete spontaneous bowel movements (CSBMs) and an average straining score ≥3.0 (CIC; 5-point scale) or ≥8.0 (IBS-C; 11-point scale) during a 2-week screening. Primary efficacy endpoints were durable overall CSBM responders (CIC: ≥3 CSBMs/week, plus increase from baseline of ≥1 CSBM/week, for ≥9 of 12 weeks, including ≥3 of the last 4 weeks) and overall responders (IBS-C: ≥30% reduction from baseline in abdominal pain and ≥1 CSBM/week increase for ≥6 of 12 weeks). KEY RESULTS: Severe constipation was observed in 24.5% (646/2639) and 24.2% (527/2176) of CIC and IBS-C populations, respectively. The CIC durable overall CSBM response rate (plecanatide 3 mg, 20.9%; plecanatide 6 mg, 20.2%; placebo, 11.3%) and IBS-C overall response rate (plecanatide 3 mg, 33.0%; plecanatide 6 mg, 31.0%; placebo, 19.0%) were significantly greater with plecanatide versus placebo (p ≤ 0.01 for all). Median time to first CSBM in CIC and IBS-C populations were significantly shorter with plecanatide 3 mg versus placebo (p = 0.01 for both). CONCLUSIONS AND INFERENCES: Plecanatide was effective in the treatment of severe constipation in adults with CIC or IBS-C.

An update on utilising brain natriuretic peptide for risk stratification, monitoring and guiding therapy in heart failure.

INTRODUCTION: Heart failure (HF) is a dominant health problem with an overall poor prognosis. Natriuretic peptides (NPs) are upregulated in HF as a compensatory mechanism. They have been extensively used for diagnosis and risk stratification. AREAS COVERED: This review addresses the history and physiology of NPs in order to understand their current role in clinical practice. It further provides a detailed and updated narrative review on the utility of those biomarkers for risk stratification, monitoring, and guiding therapy in HF. EXPERT OPINION: NPs show excellent predictive ability in heart failure patients, both in acute and chronic settings. Understanding their pathophysiology and their modifications in specific situations is key for an adequate interpretation in specific clinical scenarios in which their prognostic value may be weaker or less well evaluated. To better promote risk stratification in HF, NPs should be integrated with other predictive tools to develop multiparametric risk models. Both inequalities of access to NPs and evidence caveats and limitations will need to be addressed by future research in the coming years.

Influence of Demographic Factors on Clinical Outcomes in Adults With Chronic Idiopathic Constipation Treated With Plecanatide.

INTRODUCTION: Chronic idiopathic constipation (CIC) is a common condition that affects some patient groups more often. Demographic/clinical characteristics can differ in presentation and therapeutic response. The impact of these characteristics on plecanatide efficacy/safety was examined. METHODS: Data from 2 identically designed, randomized, phase 3 trials of adults with CIC receiving 3 mg of plecanatide, 6 mg of plecanatide, or placebo for 12 weeks were analyzed. Subgroups were baseline age, body mass index (BMI), race/ethnicity, and sex/gender. Endpoints included durable overall complete spontaneous bowel movement (CSBM) responder rate, weekly CSBMs and spontaneous bowel movements (SBMs), and adverse events. RESULTS: Overall (N = 2,639; 3 mg of plecanatide [n = 877]; 6 mg of plecanatide [n = 877]; and placebo [n = 885]), CSBM responder rates were significantly greater with 3 mg of plecanatide and 6 mg of plecanatide vs placebo in subgroups with those younger than 65 years ( P < 0.001), females ( P < 0.001), White individuals ( P < 0.001), and BMI <25 kg/m 2 ( P ≤ 0.004) and 25-30 kg/m 2 ( P < 0.001); as well, for 3 mg: 65 years or older ( P = 0.03), non-White individuals ( P < 0.001), and BMI ≥30 kg/m 2 ( P = 0.02). Improvement from baseline in weekly CSBM and SBM frequency occurred in all subgroups for both plecanatide doses vs placebo ( P ≤ 0.02) at week 12, except those aged 65 years or older for 6 mg of plecanatide. The most common adverse event was diarrhea (3 mg [4.9%]; 6 mg [5.4%]; and placebo [1.3%]). DISCUSSION: Pooled data from identically designed CIC trials strengthened the ability to identify meaningful subgroup comparisons regarding plecanatide efficacy and safety.

Peptídeos Natriuréticos tipo B (BNP e NT-ProBNP) para pacientes de 18 a 44 anos com insuficiência cardíaca / Type B Natriuretic Peptides (BNP and NT-ProBNP) for patients 18 to 44 years old with heart failure

INTRODUÇÃO: A dosagem dos níveis séricos de peptídeos natriuréticos cerebrais (BNP e o Nterminal do pró-hormônio do peptídeo natriurético do tipo B - NT-proBNP) é frequentemente utilizada em pacientes elegíveis para estabelecer o diagnóstico e a gravidade da insuficiência cardíaca. Na Diretriz do Ministério da Saúde preconiza-se a dosagem de peptídeos natriuréticos tipo B (BNP ou NT-proBNP) em duas situações: 1. Diagnóstico de IC de forma complementar à ecocardiografia nos casos com risco baixo a moderado e suspeita da doença; 2. Critério para a utilização de sacubitril/valsartana. O procedimento de dosagem de peptídeos natriuréticos tipo B (NBP e NT-proBNP) foi incorporado ao Sistema Único de Saúde em 2020 por meio da Portaria (retificação) n°296 de 03/04/2020 da Secretaria de Atenção Especializada à Saúde (SAES). Neste momento estabeleceu-se como idade mínima para acesso ao procedimento a de 45 anos. Entretanto, em 2021, por meio da Portaria n° 78 de 27/01/21 da SAES incorporou-se o medicamento sacubitril/valsartana para o tratamento de insuficiência cardíaca com fração de ejeção reduzida em pacientes classificados, segundo a New York Heart Association (NYHA), na classe II, com idade inferior a 75 anos e com elevação dos peptídeos cerebrais natriuréticos. Segundo a Portaria n° 78 de 2021, estabeleceu-se um limite inferior de idade de 18 anos para ter acesso ao medicamento. Dessa forma, faz-se necessário expandir a faixa etária elegível para ter acesso ao procedimento de dosagem de peptídeos natriuréticos para incluir o segmento de 18 a 44 anos. EVIDÊNCIAS CLÍNICAS: A Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde (SCTIE) tornou pública, por meio da publicação da Portaria nº 40, de 8 de agosto de 2019, a decisão de incorporar o sacubitril/valsartana para o tratamento de insuficiência cardíaca crônica em pacientes com classe funcional NYHA II e BNP > 150 (ou NTProBNP > 600), com fração de ejeção reduzida (FEVE < ou = 35%), idade menor ou igual a 75 anos e refratários ao melhor tratamento disponível, no âmbito do Sistema Único de Saúde ­ SUS. Dessa forma, a recomendação da Comissão acatada pela SCTIE já previa a utilização da dosagem de peptídeos natriuréticos do tipo B em adultos diagnosticados com insuficiência cardíaca e com indicação inicial de tratamento com sacubitril/valsartana. Entende-se, portanto, que seja dispensável uma nova análise de evidências clínicas sobre a utilização da dosagem desses peptídeos na faixa etária de 18 a 44 anos. ANÁLISE DE IMPACTO ORÇAMENTÁRIO: Elaborou-se uma análise de impacto orçamentário na perspectiva do Sistema Único de Saúde no horizonte temporal de cinco anos a partir da série histórica da produção ambulatorial do procedimento de dosagem de peptídeos natriuréticos tipo B no SUS. Por meio de regressão linear estimou-se a provável produção do exame para o período de 2023 a 2024 para indivíduos na faixa etária acima de 45 anos. Em seguida, por proporcionalidade, utilizando como balizador a incidência da doença nas diferentes faixas etárias (maiores que 45 anos e entre 18 e 44 anos) derivou-se o número de exames esperados para a população mais jovem. O impacto orçamentário incremental estimado para a ampliação do procedimento de dosagem de peptídeo a natriuréticos para a faixa etária de 18 a 44 anos variou entre R$ 96.876 e R$ R$ 97.864, para os anos de 2023 e 2027, respectivamente, somando no período de cinco anos aproximadamente R$ 500.000,00. MONITORAMENTO DO HORIZONTE TECNOLÓGICO: Após buscas nas bases ClinicalTrials e Cortelis foram encontradas cinco tecnologias já com registro na Anvisa que são compatíveis com a realização da dosagem de peptídeos natriuréticos tipo B. CONSIDERAÇÕES FINAIS: Este relatório sofreu uma ampla modificação em relação à versão incialmente submetida para a Conitec. Isso ocorreu porque a primeira versão fora elaborada em momento anterior à possibilidade de acessar os dados consolidados sobre a produção ambulatorial dos procedimentos de dosagem dos peptídeos natriuréticos e também sobre a utilização de sacubitril/valsartana. No momento em que esses dados consolidados foram avaliados, como explicou-se no relatório, identificou-se que uma análise de impacto orçamentário baseada em demanda epidemiológica causaria uma grande distorção em relação à real projeção de exames que seriam realizados entre 2023 e 2027. Essa percepção se formou pela análise dos dados referentes ao número de serviços no SUS que vem ofertando o serviço de dosagem dos peptídeos natriuréticos no período de 2020 a 2022, ainda reduzido e em ampliação. Isso significa que o serviço vem se estruturando para que possam ofertar esse serviço e seria de fato o fator determinante do número de procedimentos realizados no SUS. Desta forma, optouse por refazer a análise com dados de demanda aferida. RECOMENDAÇÃO PRELIMINAR DA CONITEC: Durante a 115ª reunião ordinária da Conitec em 1º de dezembro de 2022 o plenário emitiu por unanimidade recomendação favorável à ampliação de uso do procedimento de dosagem de peptídeos natriuréticos tipo B (BNP e NT-ProBNP) para a fixa etária de 18 a 44 anos. RECOMENDAÇÃO FINAL DA CONITEC: Pelo exposto, os membros do Comitê de Produtos e Procedimentos presentes na 116ª Reunião Ordinária, realizada no dia 15 de março de 2023, deliberaram, por unanimidade, recomendar a ampliação de uso da dosagem de peptídeos natriuréticos tipo B (BNP e NT-ProBNP) para o diagnóstico da insuficiência cardíaca em pacientes de 18 a 44 anos no SUS, conforme as Diretrizes Brasileiras para Diagnóstico e Tratamento da Insuficiência Cardíaca com Fração de Ejeção Reduzida. Por fim, foi assinado o Registro de Deliberação nº 802/2023. DECISÃO: Ampliar o uso do procedimento de dosagem de peptídeos natriuréticos tipo B (BNP e NT-ProBNP) para a fixa etária de 18 a 44 anos, conforme as Diretrizes Brasileiras para Diagnóstico e Tratamento da Insuficiência Cardíaca com Fração de Ejeção Reduzida, no âmbito do Sistema Único de Saúde - SUS, publicada no Diário Oficial da União nº 89, seção 1, página 222, em 11 de maio de 2023.

Dose-dependent Effects of PRC2 and HDAC Inhibitors on Cardiomyocyte Hypertrophy Induced by Phenylephrine.

INTRODUCTION: Postnatal cardiomyocytes respond to stress signals by hypertrophic growth and fetal gene reprogramming, which involves epigenetic remodeling mediated by histone methyltransferase polycomb repressive complex 2 (PRC2) and histone deacetylases (HDACs). However, it remains unclear to what extent these histone modifiers contribute to the development of cardiomyocyte hypertrophy. METHODS: Neonatal rat ventricular myocytes (NRVMs) were stimulated by phenylephrine (PE; 50µM) to induce hypertrophy in the presence or absence of the PRC2 inhibitor GSK126 or the HDACs inhibitor Trichostatin A (TSA). Histone methylation and acetylation were measured by Western blot. Cell size was determined by wheat germ agglutinin (WGA) staining. Cardiac hypertrophy markers were quantified by quantitative reverse transcription polymerase chain reaction (qRT-PCR). RESULTS: PE treatment induced the expression of cardiac hypertrophy markers, including natriuretic peptide A (Nppa), natriuretic peptide B (Nppb), and myosin heavy chain 7 (Myh7), in a time-dependent manner in NRVMs. Histone modifications, including H3K27me3, H3K9ac, and H3K27ac, were dynamically altered after PE treatment. Treatment with TSA and GSK126 dose-dependently repressed histone acetylation and methylation, respectively. While TSA reversed the PE-induced cell size enlargement in a wide range of concentrations, cardiomyocyte hypertrophy was only inhibited by GSK126 at a higher dose (1µM). Consistently, TSA dose-dependently suppressed the induction of Nppa, Nppb, and Myh7/Myh6 ratio, while these indexes were only inhibited by GSK126 at 1µM. However, TSA, but not GSK126, caused pro-hypertrophic expression of pathological genes at the basal level. CONCLUSION: Our data demonstrate diversified effects of TSA and GSK126 on PE-induced cardiomyocyte hypertrophy, and shed light on epigenetic reprogramming in the pathogenesis of cardiac hypertrophy.

Effect of sacubitril/valsartan on natriuretic peptide in patients with compensated heart failure.

The time-dependent changes in the natriuretic peptide families during sacubitril/valsartan (S/V) treatment remain obscure in the Asian heart failure (HF) cohort. Eighty-one outpatients with compensated HF were analyzed. The patients were divided into two groups based on the administration of S/V (n = 42) or angiotensin converting enzyme inhibitor (ACE-I; n = 39). Changes to the natriuretic peptide families and the daily dose of loop diuretics were evaluated 3 and 6 months after the intervention. The atrial natriuretic peptide (ANP) level was significantly increased (102 [63-160] pg/mL to 283 [171-614] pg/mL [3 months]; 409 [210-726] pg/mL [6 months]) in the S/V group but not in the ACE-I group. The dose of furosemide was significantly decreased during the six-month follow-up period in the S/V group (40 [20-40] mg to 20 [10-20] mg) but not in the ACE-I group. A multivariate logistic regression model showed that the presence of persistent atrial fibrillation (AF) and HF with a preserved left ventricular ejection fraction (HFpEF) was independently associated with a high delta-ANP ratio (≥ 4.5 ANP value on the start date/ANP value at 6 months; the mean value was used as the cutoff value) (odds ratio [OR]: 4.649, 95% CI 1.032-20.952 and OR: 7.558, 95% CI 1.427-40.042). The plasma level of ANP was increased, and the loop diuretic dose was decreased by the addition of neprilysin inhibitor therapy in patients with compensated HF. In patients with HFpEF and complicated persistent AF, neprilysin inhibitor therapy was associated with an increase in ANP.

Pharmacologic blockade of the natriuretic peptide clearance receptor promotes weight loss and enhances insulin sensitivity in type 2 diabetes.

While natriuretic peptides (NPs) are primarily known for their renal and cardiovascular actions, NPs stimulate lipolysis in adipocytes and induce a thermogenic program in white adipose tissue (WAT) that resembles brown fat. The biologic effects of NPs are negatively regulated by the NP clearance receptor (NPRC), which binds and degrades NPs. Knockout (KO) of NPRC protects against diet induced obesity and improves insulin sensitivity in obese mice. To determine if pharmacologic blockade of NPRC enhanced the beneficial metabolic actions of NPs in type 2 diabetes, we blocked NP clearance in a mouse model of type 2 diabetes using the specific NPRC ligand ANP(4-23). We found that treatment with ANP(4-23) caused a significant decrease in body weight by increasing energy expenditure and reducing fat mass without a change in lean body mass. The decrease in fat mass was associated with a significant improvement in insulin sensitivity and reduced serum insulin levels. These beneficial effects were accompanied by a decrease in infiltrating macrophages in adipose tissue, and reduced expression of inflammatory markers in both serum and WAT. These data suggest that inhibiting NP clearance may be an effective pharmacologic approach to promote weight loss and enhance insulin sensitivity in type 2 diabetes. Optimizing the therapeutic approach may lead to useful therapies for obesity and type 2 diabetes.

Natriuretic peptide pathways in heart failure: further therapeutic possibilities.

The discovery of the heart as an endocrine organ resulted in a remarkable recognition of the natriuretic peptide system (NPS). Specifically, research has established the production of atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP) from the heart, which exert pleiotropic cardiovascular, endocrine, renal, and metabolic actions via the particulate guanylyl cyclase A receptor (GC-A) and the second messenger, cGMP. C-type natriuretic peptide (CNP) is produced in the endothelium and kidney and mediates important protective auto/paracrine actions via GC-B and cGMP. These actions, in part, participate in the efficacy of sacubitril/valsartan in heart failure (HF) due to the augmentation of the NPS. Here, we will review important insights into the biology of the NPS, the role of precision medicine, and focus on the phenotypes of human genetic variants of ANP and BNP in the general population and the relevance to HF. We will also provide an update of the existence of NP deficiency states, including in HF, which provide the rationale for further therapeutics for the NPS. Finally, we will review the field of peptide engineering and the development of novel designer NPs for the treatment of HF. Notably, the recent discovery of a first-in-class small molecule GC-A enhancer, which is orally deliverable, will be highlighted. These innovative designer NPs and small molecule possess enhanced and novel properties for the treatment of HF and cardiovascular diseases.

Alerta monitoramento do horizonte tecnológico: Vosoritida para o tratamento de Acondroplasia / Technological horizon monitoring alert: Vosoritida for the treatment of Achondroplasia

A TECNOLOGIA: Descrição da tecnologia: A vosoritida é uma molécula análoga ao peptídeo natriurético do tipo C (CNP ­ do inglês: C-type natriuretic peptide), um hormônio natural que regula o crescimento linear dos ossos. Esse medicamento inibe a via da proteína quinase, que ativa a jusante do receptor do fator de crescimento de fibroblastos 3 (FGFR3). Como resultado, a vosoritida atua como um regulador positivo da ossificação endocondral, uma vez que promove a proliferação e diferenciação dos condrócitos. Condição clínica: A acondroplasia é uma doença genética rara descrita como a displasia esquelética primária mais comum em humanos. Essa forma de displasia é responsável por mais de 90% dos casos de baixa estatura desproporcional, também conhecida como nanismo. Etimologicamente, o termo acondroplasia significa "sem formação de cartilagem" e é categorizada como uma displasia fisária (da placa de crescimento). A acondroplasia ocorre em aproximadamente 1:20.000 a 1:30.000 nascidos vivos por ano. Por difícil que seja determinar a prevalência global dessa condição, estima-se que ela afete aproximadamente 1 a 9 indivíduos por 100.000 da população geral. Um extenso estudo epidemiológico de base populacional europeu calculou a prevalência em 3,72 por 100.000 nascimentos (8). Esse estudo demonstrou que a prevalência foi estável ao longo do tempo, contudo, foram observadas diferenças regionais. INFORMAÇÕES REGULATÓRIAS: Informações sobre registro: A vosoritida foi registrada em 29/11/2021 na Agência Nacional de Vigilância Sanitária (Anvisa) como um produto novo, cumprindo com o disposto na RDC nº 55/2010 para o registro de produtos biológicos novos. Por se tratar de uma necessidade médica não atendida atualmente, este produto foi priorizado de acordo com os critérios da RDC nº 204/2017 e nas agências reguladoras internacionais para as seguintes indicações clínicas: Agência Nacional de Vigilância Sanitária (Anvisa): indicado para o tratamento de acondroplasia (ACH) em pacientes a partir de 2 anos de idade e cujas epífises não estão fechadas. O diagnóstico de acondroplasia deve ser confirmado por teste genético apropriado. U.S. Food and Drug Administration (FDA): é indicado para aumentar o crescimento linear em pacientes pediátricos com acondroplasia com 5 anos de idade ou mais com epífises abertas. Essa é uma autorização contingente, o que significa que para ser mantida, os benefícios clínicos deverão ser confirmados por ensaio clínico. European Medicines Agency (EMA): é indicado para o tratamento da acondroplasia em crianças a partir dos dois anos de idade até o fechamento das placas de crescimento. Pharmaceuticals and Medical Devices Agency (PMDA): é indicado para o tratamento de crianças de todas as idades que ainda não tiveram o fechamento das placas de crescimento. PANORAMA DE DESENVOLVIMENTO: Estratégia de busca: A estratégia de busca foi composta por duas etapas. A primeira objetivou identificar os registros de estudos clínicos do vosoritida para o tratamento de acondroplasia no ClinicalTrials.gov e no Cortellis. A busca no Cortellis foi realizada em 17 de agosto de 2022 com o termo 'vosoritide'. Já a busca no ClinicalTrials foi realizada em 19 de agosto de 2022 com os termos 'vosoritide' e 'achondroplasia'. Foram incluídos ensaios clínicos, randomizados ou não, a partir da fase 2, em que o vosoritida tenha sido utilizado para o tratamento da acondroplasia. Não houve restrição quanto ao idioma. Não foram incluídas análises post hocs, pool analysis. Na segunda etapa, foi realizada busca nas bases Medline e PMC (via PubMed) e Embase (via Portal Periódicos Capes) com o objetivo de localizar estudos publicados e não publicados referentes aos ensaios clínicos conduzidos que utilizaram o vosoritida no tratamento da acondroplasia. Desta forma, foram construídas estratégias de busca utilizando termos controlados e seus respectivos sinônimos (Apêndice 1). Estas buscas foram realizadas em 5 de setembro de 2022. CONSIDERAÇÕES FINAIS: A acondroplasia é causada por mutações no gene do receptor 3 do fator de crescimento de fibroblastos, que levam à ossificação endocondral prejudicada. O medicamento vosoritida é um análogo do peptídeo natriurético tipo C, que foi desenvolvido para o tratamento de crianças portadoras dessa doença. Os resultados disponíveis, até a última atualização deste alerta, foram promissores e subsidiaram o registro da vosoritida em vários países, inclusive no Brasil. Mas é importante destacar que devido à variabilidade do crescimento e ao menor pico de crescimento durante a puberdade, em crianças com acondroplaisa, os efeitos a longo prazo da vosoritida só serão conhecidos quando as crianças atingirem a altura adulta final.

Cardio-oncology in Austria: cardiotoxicity and surveillance of anti-cancer therapies : Position paper of the Heart Failure Working Group of the Austrian Society of Cardiology.

Survival in cancer is continuously improving due to evolving oncological treatment. Therefore, cardiovascular short-term and long-term side effects gain crucial importance for overall outcome. Cardiotoxicity not only presents as heart failure, but also as treatment-resistant hypertension, acute coronary ischemia with plaque rupture or vasospasm, thromboembolism, arrhythmia, pulmonary hypertension, diastolic dysfunction, acute myocarditis and others. Recent recommendations have proposed baseline cardiac risk assessment and surveillance strategies. Major challenges are the availability of monitoring and imaging resources, including echocardiography with speckle tracking longitudinal strain (GLS), serum biomarkers such as natriuretic peptides (NT-proBNP) and highly sensitive cardiac troponins. This Austrian consensus encompasses cardiotoxicity occurrence in frequent antiproliferative cancer drugs, radiotherapy, immune checkpoint inhibitors and cardiac follow-up considerations in cancer survivors in the context of the Austrian healthcare setting. It is important to optimize cardiovascular risk factors and pre-existing cardiac diseases without delaying oncological treatment. If left ventricular ejection fraction (LVEF) deteriorates during cancer treatment (from >10% to <50%), or myocardial strain decreases (>15% change in GLS), early initiation of cardioprotective therapies (angiotensin-converting enzyme inhibitors, angiotensin or beta receptor blockers) is recommended, and LVEF should be reassessed before discontinuation. Lower LVEF cut-offs were recently shown to be feasible in breast cancer patients to enable optimal anticancer treatment. Interdisciplinary cardio-oncology cooperation is pivotal for optimal management of cancer patients.

Epicardial fat and incident heart failure with preserved ejection fraction in patients with coronary artery disease.

BACKGROUND: We aimed to determine, whether epicardial adipose tissue (EAT) as local source of inflammation, as well as its change over time, associates with the development of heart failure with preserved ejection fraction (HFpEF) in patients with coronary artery disease. METHODS AND RESULTS: We retrospectively included 379patients (aged 65.2 ± 11.7 years, 70.2%male) with coronary artery disease but without heart failure at baseline, undergoing clinical and echocardiographic assessment in 2010-2013 and receiving a second assessment in 2014-2018. EAT thickness was defined as space between the myocardium and the pericardium and indexed (EATi) by body surface area. Change in EATi was calculated as the difference of follow-up and baseline EATi. HFpEF was defined according to presence of dyspnea, elevated natriuretic peptides, and structural and/or functional alterations on echocardiography in accordance with current European Society of Cardiology guidelines. During a median follow-up of 4.3 years, 142patients (37.5%) developed HFpEF. Patients with onset of HFpEF had higher EATi at baseline (2.4 ± 1.3 vs. 1.9 ± 0.9 mm/m2, p = 0.001). In multivariable regression analysis, EATi associated with onset of HFpEF (1.25 [1.01-1.54], p = 0.04). Likewise, an increase in EATi over time was linked HFpEF development, independent of other risk factors and baseline EATi (1.39 [1.04-1.87], p = 0.03). EATi was significantly associated with follow-up b-type natriuretic peptide (BNP) levels (4.31[0.58-8.05], p = 0.024), but not with baseline BNP (2.24[-0.27-4.76], p = 0.08). CONCLUSION: EATi is associated with the development of HFpEF. The finding of changes in EATi altering the risk of HFpEF manifestation support the rationale for further research on epicardial fat modulation as a treatment target for HFpEF.

Modified natriuretic peptides and their potential roles in cancer treatment.

The natriuretic peptide family (NPs) is a group of natural endocrine hormones, containing a 17-amino acid ring structure connected by disulfide bonds of two cysteines. In this review, the members of the natriuretic peptide family and their corresponding receptors as well as the anti-cancer effects are introduced. Four cardiac hormones of NPs (ANP, VD, KP and LANP) can effectively inhibit the growth of human small cell lung cancer, breast cancer and other tumors and significantly reduce tumor volume in vivo. The in vitro experiments also show that cardiac hormones, CNP and urodilatin can effectively inhibit the growth of most tumor cells. We then further summarized the anti-cancer mechanism of natriuretic peptides. Finally, we introduce several methods that modify natriuretic peptides, leading to enhance their stability and prolong the biological effects of these peptides, which might be helpful for the clinical application in the future. Peptide therapy is a very promising field for cancer treatments since they can induce the death of cancer cells without dramatically affecting normal cells. The synthesis of a useful and stable natriuretic peptide can enhance the effect of cancer treatments and significantly reduce drug resistance and toxicity.

The natriuretic peptide system in heart failure: Diagnostic and therapeutic implications.

Natriuretic peptides, which are activated in heart failure, play an important cardioprotective role. The most notable of the cardioprotective natriuretic peptides are atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), which are abundantly expressed and secreted in the atrium and ventricles, respectively, and C-type natriuretic peptide (CNP), which is expressed mainly in the vasculature, central nervous system, and bone. ANP and BNP exhibit antagonistic effects against angiotensin II via diuretic/natriuretic actions, vasodilatory actions, and inhibition of aldosterone secretion, whereas CNP is involved in the regulation of vascular tone and blood pressure, among other roles. ANP and BNP are of particular interest with respect to heart failure, as their levels, most notably BNP and N-terminal proBNP-a cleavage product produced when proBNP is processed to mature BNP-are increased in patients with heart failure. Furthermore, the identification of natriuretic peptides as sensitive markers of cardiac load has driven significant research into their physiological roles in cardiovascular homeostasis and disease, as well as their potential use as both biomarkers and therapeutics. In this review, I discuss the physiological functions of the natriuretic peptide family, with a particular focus on the basic research that has led to our current understanding of its roles in maintaining cardiovascular homeostasis, and the pathophysiological implications for the onset and progression of heart failure. The clinical significance and potential of natriuretic peptides as diagnostic and/or therapeutic agents are also discussed.

Protection of kidney function and tissue integrity by pharmacologic use of natriuretic peptides and neprilysin inhibitors.

With variable potencies atrial-, brain-type and c-type natriuretic peptides (NP)s, best documented for ANP and its analogues, promote sodium and water excretion, renal blood flow, lipolysis, lower blood pressure, and suppress renin and aldosterone secretion through interaction predominantly with cGMP-coupled NPR-A receptor. Infusion of especially ANP and its analogues up to 50 ng/kg/min in patients with high risk of acute kidney injury (cardiac vascular bypass surgery, intraabdominal surgery, direct kidney surgery) protects kidney function (GFR, plasma flow, medullary flow, albuminuria, renal replacement therapy, tissue injury) at short term and also long term and likely additively with the diuretic furosemide. This documents a pharmacologic potential for the pathway. Neprilysin (NEP, neutral endopeptidase) degrades NPs, in particular ANP, and angiotensin II. The drug LCZ696, a mixture of the neprilysin inhibitor sacubitril and the ANGII-AT1 receptor blocker valsartan, was FDA approved in 2015 and marketed as Entresto®. In preclinical studies of kidney injury, LCZ696 and NPs lowered plasma creatinine, countered hypoxia and oxidative stress, suppressed proinflammatory cytokines, and inhibited fibrosis. Few randomized clinical studies exist and were designed with primary cardiac outcomes. The studies showed that LCZ696/entresto stabilized and improved glomerular filtration rate in patients with chronic kidney disease. LCZ696 is safe to use concerning kidney function and stabilizes or increases GFR. In perspective, combined AT1 and neprilysin inhibition is a promising approach for long-term renal protection in addition to AT1 receptor blockers in acute kidney injury and chronic kidney disease.

Natriuretic Peptides as the Basis of Peptide Drug Discovery for Cardiovascular Diseases.

Cardiovascular diseases (CVDs) are the leading global cause of death, accounting for more than 17.6 million deaths per year in 2016, a number that is expected to grow to more than 23.6 million by 2030. While many technologies are currently under investigation to improve the therapeutic outcome of CVD complications, only a few medications have been approved. Therefore, new approaches to treat CVD are urgently required. Peptides regulate numerous physiological processes, mainly by binding to specific receptors and inducing a series of signals, neurotransmissions or the release of growth factors. Importantly, peptides have also been shown to play an important role in the circulatory system both in physiological and pathological conditions. Peptides, such as angiotensin II, endothelin, urotensin-II, urocortins, adrenomedullin and natriuretic peptides have been implicated in the control of vascular tone and blood pressure as well as in CVDs such as congestive heart failure, atherosclerosis, coronary artery disease, and pulmonary and systemic hypertension. Hence it is not surprising that peptides are becoming important therapeutic leads in CVDs. This article will review the current knowledge on peptides and their role in the circulatory system, focusing on the physiological roles of natriuretic peptides in the cardiovascular system and their implications in CVDs.