The Angiotensin Antagonist Losartan Modulates Social Reward Motivation and Punishment Sensitivity via Modulating Midbrain-Striato-Frontal Circuits.

Social deficits and dysregulations in dopaminergic midbrain-striato-frontal circuits represent transdiagnostic symptoms across psychiatric disorders. Animal models suggest that interactions between the dopamine (DA) and renin-angiotensin system (RAS) may modulate learning and reward-related processes. The present study therefore examined the behavioral and neural effects of the Angiotensin II type 1 receptor (AT1R) antagonist losartan on social reward and punishment processing in humans. A preregistered randomized double-blind placebo-controlled between-subject pharmacological design was combined with a social incentive delay (SID) functional MRI (fMRI) paradigm during which subjects could avoid social punishment or gain social reward. Healthy volunteers received a single-dose of losartan (50 mg, n = 43, female = 17) or placebo (n = 44, female = 20). We evaluated reaction times (RTs) and emotional ratings as behavioral and activation and functional connectivity as neural outcomes. Relative to placebo, losartan modulated the reaction time and arousal differences between social punishment and social reward. On the neural level the losartan-enhanced motivational salience of social rewards was accompanied by stronger ventral striatum-prefrontal connectivity during reward anticipation. Losartan increased the reward-neutral difference in the ventral tegmental area (VTA) and attenuated VTA associated connectivity with the bilateral insula in response to punishment during the outcome phase. Thus, losartan modulated approach-avoidance motivation and emotional salience during social punishment versus social reward via modulating distinct core nodes of the midbrain-striato-frontal circuits. The findings document a modulatory role of the renin-angiotensin system in these circuits and associated social processes, suggesting a promising treatment target to alleviate social dysregulations.SIGNIFICANCE STATEMENT Social deficits and anhedonia characterize several mental disorders and have been linked to the midbrain-striato-frontal circuits of the brain. Based on initial findings from animal models we here combine the pharmacological blockade of the Angiotensin II type 1 receptor (AT1R) via losartan with functional MRI (fMRI) to demonstrate that AT1R blockade enhances the motivational salience of social rewards and attenuates the negative impact of social punishment via modulating the communication in the midbrain-striato-frontal circuits in humans. The findings demonstrate for the first time an important role of the AT1R in social reward processing in humans and render the AT1R as promising novel treatment target for social and motivational deficits in mental disorders.

Renin Production by Juxtaglomerular Cell Tumors and Clear Cell Renal Cell Carcinoma and the Role of Angiotensin Signaling Inhibitors.

OBJECTIVE: To profile juxtaglomerular cell tumors (JXG) and histologic mimics by analyzing renin expression; to identify non-JXG renin-producing tumors in The Cancer Genome Atlas (TCGA) data sets; and to define the prevalence of hypertension (HTN) and patient outcomes with angiotensin signaling inhibitor (ASI) use in tumors of interest. PATIENTS AND METHODS: Thirteen JXGs and 10 glomus tumors (GTs), a histologic mimic, were evaluated for clinicopathologic features; TCGA data were analyzed to identify non-JXG renin-overexpressing tumors. An institutional registry was queried to determine the incidence of HTN, the use of ASIs in hypertensive patients, and the impact of ASIs on outcomes including progression-free survival (PFS) in a tumor type with high renin expression (clear cell renal cell carcinoma [CC-RCC] diagnosed between January 1, 2005, and December 31, 2012). RESULTS: We found an association between renin production and HTN in JXG compared with GT. Analysis of TCGA data found that a subset of CC-RCCs overexpress renin relative to 29 other tumor types. Furthermore, analysis of our institutional registry revealed a high prevalence (64%) of HTN among 1203 patients treated with radical or partial nephrectomy for nonmetastatic CC-RCC. On multivariable Cox regression, patients with HTN treated with ASIs (34%) had improved PFS (hazard ratio, 0.76; 95% CI, 0.57 to 1.00; P=.05) compared with patients with HTN not treated with ASIs (30%). CONCLUSION: The identification of renin expression in a subset of CC-RCC may provide a biologic rationale for the high prevalence of HTN and improved PFS with ASI use in hypertensive patients with nonmetastatic CC-RCC.

Renin-angiotensin system in intestinal inflammation-Angiotensin inhibitors to treat inflammatory bowel diseases?

Inflammatory bowel diseases (IBDs) are chronic disorders of the gastrointestinal tract, which manifest in recurring gastrointestinal inflammation. The current treatment options of IBD are not curative and are lacking in aspects like prevention of fibrosis. New treatment options are needed to fulfil the unmet needs and provide alternatives to drugs with resistances and side effects. Drugs targeting the renin-angiotensin system (RAS), besides being antihypertensive, also possess anti-inflammatory and antifibrotic properties and could offer an inexpensive alternative to control inflammation and fibrosis in the gut. RAS inhibitors have been effective in preventing and alleviating colitis in preclinical studies, but available human data are still sparse. This review outlines the pathophysiological functions of RAS in the gut and summarizes preclinical studies utilizing pharmacological RAS inhibitors in the treatment of experimental colitis. We discuss the alterations in intestinal RAS and the available evidence of the benefits of RAS inhibitors for IBD patients. Retrospective studies comparing IBD patients using ACE inhibitors or angiotensin II receptor blockers have provided optimistic results regarding a milder disease course and fewer hospitalizations and corticosteroid use in patients using RAS inhibitors. Prospective studies are needed to evaluate the effectiveness of these promising medications in the treatment of IBD.

Polyphenolic Composition and in Vitro Antihypertensive and Anti-Inflammatory Effects of Cuphea lindmaniana and Cuphea urbaniana.

The present study investigates the chemical composition, anti-inflammatory, and antihypertensive activities, in vitro, from extracts of Cuphea lindmaniana and Cuphea urbaniana leaves. The extraction was performed ultrasound-assisted, and UHPLC/MS analysis was in positive mode ionization. The anti-inflammatory activity of the extracts and miquelianin were assayed at concentrations 0.001-10 µg/mL by chemotaxis on rat polymorphonuclear neutrophils. The antihypertensive activity was performed by angiotensin-converting enzyme (ACE) inhibition. From the nineteen proposed compounds, six of them are described for the first time in this genus. The extracts displayed antichemotactic effect with a reduction of 100 % of the neutrophil migration, in vitro, in most concentrations. The ACE-inhibition presented results ranging from 19.58 to 22.82 %. In conclusion, C. lindmaniana and C. urbaniana extracts contain a rich diversity of flavonoids and display in vitro anti-inflammatory and antihypertensive potential. Thus, this study could serve as a scientific baseline for further investigation, on developmental novel products with therapeutic actions.

Drug-related challenges following primary total hip and knee arthroplasty.

We aimed to characterize the in-hospital analgesic use among total hip or knee arthroplasty (THA or TKA) patients, and to identify possible drug-related challenges. We identified 15 263 patients operated with a THA or TKA between 1 January 2012 and 30 April 2016. The prevalence of analgesic users and patients with potential clinically relevant drug-drug interactions (DDIs), along with the prevalence of readmission among patients with vs. without a DDI, were calculated. A DDI was defined as the combination of (A) a diuretic, an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker, and an non-steroidal anti-inflammatory Drug (NSAID); (B) warfarin and an NSAID; and (C) a benzodiazepine or a benzodiazepine-related drug and an opioid. The prevalence of analgesics administered in THA and TKA patients was 99.3% and 99.1% for paracetamol and 93.8% and 98.8% for opioids, respectively. The prevalence of patients who received interaction A, B or C was 8.4%, 2.5% and 40.7%, respectively. Patients with vs. without a DDI had a higher prevalence of 30-day readmission. In conclusion, most THA and TKA patients were administered paracetamol or opioids. The prevalence of 30-day readmission was higher in patients with than in patients without a potential clinically relevant DDI.

Ambulatory Treatments for RAAS Inhibitor-Related Hyperkalemia and the 1-Year Risk of Recurrence.

BACKGROUND AND OBJECTIVE: The optimal ambulatory management of renin-angiotensin-aldosterone system inhibitor (RAASi)-related hyperkalemia to reduce the risk of recurrence is unknown. We examined the risk of hyperkalemia recurrence on the basis of outpatient pharmacologic changes following an episode of RAASi-related hyperkalemia. DESIGN: We performed a population-based, retrospective cohort study of older adults (n=49,571; mean age 79 years) who developed hyperkalemia (potassium ≥5.3 mEq/L) while on a RAASi and were grouped as follows: no intervention, RAASi discontinuation, RAASi dose decrease, new diuretic, diuretic dose increase, or sodium polystyrene sulfonate within 30 days. The primary outcome was hyperkalemia recurrence, with secondary outcomes of cardiovascular events and all-cause mortality within 1 year. RESULTS: Among patients who received a pharmacologic intervention (23% of the cohort), RAASi discontinuation was the most commonly prescribed strategy (74%), followed by RAASi decrease (15%), diuretic increase (7%), new diuretic (3%), and sodium polystyrene sulfonate (1%). A total of 16,977 (34%) recurrent hyperkalemia events occurred within 1 year. Compared with no intervention (35%, referent), the cumulative incidence of recurrent hyperkalemia was lower with RAASi discontinuation (29%; hazard ratio, 0.82; 95% confidence interval, 0.78 to 0.85), whereas there was no difference with RAASi dose decrease (36%; hazard ratio, 0.94; 95% confidence interval, 0.86 to 1.02), new diuretic (32%; hazard ratio, 0.95; 95% confidence interval, 0.78 to 1.17), or diuretic increase (38%; hazard ratio, 0.99; 95% confidence interval, 0.87 to 1.12) and a higher incidence with sodium polystyrene sulfonate (55%; hazard ratio, 1.30; 95% confidence interval, 1.04 to 1.63). RAASi discontinuation was not associated with a higher risk of 1-year cardiovascular events (hazard ratio, 0.96; 95% confidence interval, 0.91 to 1.02) or all-cause mortality (hazard ratio, 1.05; 95% confidence interval, 0.96 to 1.15) compared with no intervention. CONCLUSIONS: Among older adults with RAASi-related hyperkalemia, RAASi discontinuation is associated with the lowest risk of recurrent hyperkalemia, with no apparent increase in short-term risks for cardiovascular events or all-cause mortality.

Angiotensin inhibition and cellular senescence in the developing rat kidney.

Cellular senescence is important for the maintenance of tissue homeostasis during normal development. In this study, we aimed to investigate the effect of renin angiotensin system (RAS) blockade on renal cell senescence in the developing rat kidney. Newborn rat pups were treated with enalapril (30 mg/kg/day) or vehicle for seven days after birth. We investigated the intrarenal expressions of cell cycle regulators p21 and p16 with immunoblots and immunohistochemistry at postnatal day 8. For the determination of renal cellular senescence, immunostaining for senescence-associated ß-galactosidase (SA-ß-gal) and telomerase reverse transcriptase (TERT) was also performed. Enalapril treatment showed significant alterations in cellular senescence in neonatal rat kidneys. In the enalapril-treated group, intrarenal p16 and p21 protein expressions decreased compared to controls. The expressions of both p21 and p16 were reduced throughout the renal cortex and medulla of enalapril-treated rats. The immunoreactivity of TERT in enalapril-treated kidneys was also weaker than that in control kidneys. Control kidneys revealed a clear positive SA-ß-gal signal in the cortical tubules; however, SA-ß-gal activity was noticeably lower in the enalapril-treated kidneys than in control kidneys. Interruption of the RAS during postnatal nephrogenesis may disrupt physiologic renal cellular senescence in the developing rat kidney.

Angiotensin-Neprilysin Inhibition and Renal Outcomes in Heart Failure With Preserved Ejection Fraction.

BACKGROUND: In patients with heart failure, chronic kidney disease is common and associated with a higher risk of renal events than in patients without chronic kidney disease. We assessed the renal effects of angiotensin/neprilysin inhibition in patients who have heart failure with preserved ejection fraction enrolled in the PARAGON-HF trial (Prospective Comparison of ARNI With ARB Global Outcomes in HF With Preserved Ejection Fraction). METHODS: In this randomized, double-blind, event-driven trial, we assigned 4822 patients who had heart failure with preserved ejection fraction to receive sacubitril/valsartan (n=2419) or valsartan (n=2403). Herein, we present the results of the prespecified renal composite outcome (time to first occurrence of either: ≥50% reduction in estimated glomerular filtration rate (eGFR), end-stage renal disease, or death from renal causes), the individual components of this composite, and the influence of therapy on eGFR slope. RESULTS: At randomization, eGFR was 63±19 mL·min-1·1.73 m-2. At study closure, the composite renal outcome occurred in 33 patients (1.4%) assigned to sacubitril/valsartan and 64 patients (2.7%) assigned to valsartan (hazard ratio, 0.50 [95% CI, 0.33-0.77]; P=0.001). The treatment effect on the composite renal end point did not differ according to the baseline eGFR (<60 versus ≥60 mL·min-1·1.73 m-2 (P-interaction=0.92). The decline in eGFR was less for sacubitril/valsartan than for valsartan (-2.0 [95% CI, -2.2 to -1.9] versus -2.7 [95% CI, -2.8 to -2.5] mL·min-1·1.73 m-2 per year). CONCLUSIONS: In patients with heart failure with preserved ejection fraction, sacubitril/valsartan reduced the risk of renal events, and slowed decline in eGFR, in comparison with valsartan. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01920711.

Targeting the renin-angiotensin-aldosterone system in fibrosis.

Fibrosis is characterized by excessive deposition of extracellular matrix components such as collagen in tissues or organs. Fibrosis can develop in the heart, kidneys, liver, skin or any other body organ in response to injury or maladaptive reparative processes, reducing overall function and leading eventually to organ failure. A variety of cellular and molecular signaling mechanisms are involved in the pathogenesis of fibrosis. The renin-angiotensin-aldosterone system (RAAS) interacts with the potent Transforming Growth Factor ß (TGFß) pro-fibrotic pathway to mediate fibrosis in many cell and tissue types. RAAS consists of both classical and alternative pathways, which act to potentiate or antagonize fibrotic signaling mechanisms, respectively. This review provides an overview of recent literature describing the roles of RAAS in the pathogenesis of fibrosis, particularly in the liver, heart, kidney and skin, and with a focus on RAAS interactions with TGFß signaling. Targeting RAAS to combat fibrosis represents a promising therapeutic approach, particularly given the lack of strategies for treating fibrosis as its own entity, thus animal and clinical studies to examine the impact of natural and synthetic substances to alter RAAS signaling as a means to treat fibrosis are reviewed as well.

Association between the Use of Angiotensin-Blocking Medications with Hip Fracture and Death in Older People.

It is unclear if angiotensin blocking drugs (angiotensin converting enzyme inhibitors and angiotensin receptor blockers) reduce or increase the risk of falls and fractures. We retrospectively analysed routinely-collected, linked health and social care data for patients aged 65 and over from Tayside, Scotland, including hospital discharge diagnoses, biochemistry, deaths, care package provision and community prescribing. We conducted unadjusted and adjusted Cox regression analyses for time to hip fracture and time to death, for any exposure to angiotensin blocking drugs and for time-dependent exposure to angiotensin blocking drugs. We analysed data on 16782 patients. Angiotensin blocking drug use was associated with an exposure-dependent lower risk of hip fracture (hazard ratio 0.988 [95%CI 0.982-0.994] per year of exposure; p<0.001) and death (hazard ratio 0.986 [95%CI 0.983-0.989] per year of exposure; p<0.001). These findings call into question the appropriateness of stopping angiotensin blocking drugs for older people at risk of falls.

RAS inhibition modulates kynurenine levels in a CKD population with and without type 2 diabetes mellitus.

Kynurenine pathway of tryptophan metabolism is involved in the pathophysiology of chronic kidney disease (CKD) and diabetes mellitus, mainly through the inflammation-induced activity of indoleamine 2,3-dioxygenase (IDO), and few studies have investigated its potential link with proteinuria. Renin-angiotensin system inhibitors (RASis) are recommended in these patients to decrease proteinuria, slow CKD progression and reduce cardiovascular risk, but whether these drugs influence kynurenine levels in humans is unknown. We evaluated serum tryptophan and kynurenine in patients suffering from CKD with or without type 2 diabetes mellitus, their correlations with markers of reduced kidney function, and their relationship with RAS-inhibiting therapy. Of 72 adult patients enrolled, 55 were receiving RASis, whereas 17 were not. Tryptophan was assessed by HPLC (high-performance liquid chromatography); kynurenine was measured using an enzyme-linked immunosorbent assay kit; IDO activity (%) was calculated with the formula (kynurenine/tryptophan) × 100. Kynurenine levels were significantly lower in the group under RASis compared to the untreated group (1.56 ± 0.79 vs 2.16 ± 1.51 µmol/l; P = 0.0378). In patients not receiving RASis, kynurenine was inversely related to estimated glomerular filtration rate (eGFR) (r = - 0.4862; P = 0.0478) and directly related to both proteinuria (ρ = 0.493; P = 0.0444) and albuminuria (ρ = 0.542; P = 0.0247). IDO activity was higher in patients with history of cardiovascular disease compared to patients with no such history, and it negatively correlated with eGFR (ρ = - 0.554; P = 0.0210) in the same group. These findings may contribute to explain the well-known beneficial effects of RAS inhibition in CKD population, especially considering that kynurenine is emerging as a potential new biomarker of CKD.

Should COVID-19 Concern Nephrologists? Why and to What Extent? The Emerging Impasse of Angiotensin Blockade.

Here, we review the most recent findings on the effects of SARS-CoV-2 infection on kidney diseases, including acute kidney injury, and examine the potential effects of ARBs on the outcomes of patients with COVID-19. Lastly, we discuss the clinical management of COVID-19 patients with existing chronic renal disorders, particularly those in dialysis and with kidney transplants.

Melanin-like nanoparticles loaded with an angiotensin antagonist for an improved photothermal cancer therapy.

An abnormal tumor growth induces solid stress in tumors, thus reducing blood perfusion. As a result, the impaired blood perfusion, with dense interstitial matrix in tumors significantly reduces the penetration and efficacy of nanotherapeutics. In this study, we have developed a losartan-loaded polydopamine nanoparticle (PLST) for the enhanced delivery of nanoparticles to tumors and improved photothermal cancer therapy. Losartan, an angiotensin inhibitor, is also able to alleviate the solid stress in tumors. It was laden on polydopamine nanoparticles via π-π stacking and was released upon tumor extracellular acidity. PLST reduced collagen production in vitro along with the lowered expression of profibrotic factors of TGF-ß1, CCN2, and TIMP-1. The in vivo studies reveal that PLST reduced solid stress in tumors, and the amount of PLST accumulated in tumors was enhanced. The efficiency of the photothermal ablation of tumors was significantly enhanced by using PLST.

Angiotensin involvement in trauma processing-exploring candidate neurocognitive mechanisms of preventing post-traumatic stress symptoms.

The angiotensin-II antagonist losartan is a promising candidate that has enhanced extinction in a post-traumatic stress disorder (PTSD) animal model and was related to reducing PTSD symptom development in humans. Here, we investigate the neurocognitive mechanisms underlying these results, testing the effect of losartan on data-driven and contextual processing of traumatic material, mechanisms proposed to be relevant for PTSD development. In a double-blind between-subject design, 40 healthy participants were randomised to a single oral dose of losartan (50 mg) or placebo, 1 h before being exposed to distressing films as a trauma analogue while heart rate (HR) was measured. Peritraumatic processing was investigated using blurry picture stimuli from the films, which transformed into clear images. Data-driven processing was measured by the level of blurriness at which contents were recognised. Contextual processing was measured as the amount of context information retrieved when describing the pictures' contents. Negative-matched control images were used to test perceptual processing of peripheral trauma-cues. Post-traumatic stress symptoms were assessed via self-report questionnaires after analogue trauma and an intrusion diary completed over 4 days following the experiment. Compared to placebo, losartan facilitated contextual processing and enhanced detail perception in the negative-match pictures. During the films, the losartan group recorded lower HR and higher HR variability, reflecting lower autonomic stress responses. We discuss potential mechanisms of losartan in preventing PTSD symptomatology, including the role of reduced arousal and increased contextual processing during trauma exposure, as well as increased threat-safety differentiation when encountering peripheral trauma-cues in the aftermaths of traumatic events.

Eficacia de sacubitrilo/valsartán en pacientes con insuficiencia cardiaca crónica de fracción de eyección reducida grado funcional II-IV recibiendo terapia médica óptima a dosis máxima tolerable por un tiempo mínimo de seis meses que se encuentren hospitalizados por falla cardiaca descompensada / Efficacy of sacubitril/valsartan in patients with chronic heart failure with reduced ejection fraction functional grade II-IV receiving optimal medical therapy at the maximum tolerable dose for a minimum of six months who are hospitalized for decompensated heart failure

INTRODUCCIÓN: El presente dictamen expone la evaluación de la eficacia y seguridad de sacubitrilo/valsartán en pacientes con insuficiencia cardiaca crónica (ICC) con fracción de eyección ventricular izquierda reducida (FEVI-r) de clase funcional NYHA II a IV, en terapia médica óptima (TMO) a dosis máxima tolerable (DMT) por mínimo tres meses que se encuentren hospitalizados por falla cardiaca descompensada. El sacubitrilo/valsartán ya ha sido evaluado por el IETSI a través del Dictamen Preliminar de Evaluación de Tecnología Sanitaria N° 015-SDEPFyOTS-DETS-IETSI-2018 "Eficacia y seguridad de sacubitrilo/valsartán en pacientes con insuficiencia cardiaca CF II-IV, fracción de eyección disminuida, sintomático, y en terapia médica óptima". El IETSI no aprobó el uso de sacubitrilo/valsartán debido a que un único ensayo clínico aleatorizado, el estudio PARADIGM-HR, presentó múltiples limitaciones metodológicas que finalmente no lograron demostrar superioridad en eficacia y seguridad en comparación con la terapia médica óptima. La falla cardiaca o insuficiencia cardiaca de fracción de eyección reducida es un síndrome clínico que se manifiesta sintomáticamente cuando hay un desorden cardiaco funcional o estructural que impide que el ventrículo pueda llenarse o eyectar sangre al resto del cuerpo. Por consenso, se habla de falla cardiaca con fracción de eyección (FE) reducida cuando hay una FE del ventrículo izquierdo menor a 40 %. Para clasificar la severidad de falla cardiaca con respecto a la presencia o no de síntomas, se utiliza la clasificación de clase funcional (CF) NYHA; es así, como una CF de I se da cuando el paciente es asintomático y una CF de II a IV cuando el paciente se encuentra, en diferentes niveles, sintomático. Una descompensación por falla cardiaca es un síndrome clínico agudo que por su potencial riesgo de mortalidad conduce a que el paciente se hospitalice o acuda a al servicio de emergencia. En pacientes con falla cardiaca crónica, la descompensación puede ocurrir sin un precipitante conocido, pero con mayor frecuencia se da por infecciones, hipertensión arterial no controlada, trastornos rítmicos cardiacos (taquicardia, bradicardia) o la no adherencia a la dieta o tratamiento. El manejo de la descompensación aguda por falla cardiaca no incluye los medicamentos para el manejo de falla cardiaca crónica (Inhibidores de la encima convertidora de angiotensina [IECA], antagonistas de los receptores de la angiotensina II [ARA-II], beta-bloqueadores, antagonistas de receptores de mineralocorticoides). El manejo de falla cardiaca crónica de FE reducida se realiza con la inhibición de los tres ejes del sistema renina-angiotensina-aldosterona. De esta manera, el eje de la renina es manejado con los beta-bloqueadores; el eje de la angiotensina con IECA (o ARA-II en caso de haber intolerancia a los IECA); y el eje de aldosterona con los antagonistas de aldosterona como la espironolactona. El Petitorio Farmacológico de EsSalud cuenta con diferentes opciones para cada grupo de medicamentos del manejo de falla cardiaca. No obstante, existen pacientes que a pesar de encontrarse en terapia medica óptima a máximas dosis tolerables con las opciones disponibles en la institución presentan falla cardiaca descompensada con requerimiento de hospitalización. Así, surge la necesidad de evaluar otras opciones de tratamiento para el manejo de la falla cardiaca crónica. METODOLOGÍA: Para responder la pregunta PICO de investigación (Tabla 1) se realizó una búsqueda bibliográfica sistemática abierta en las bases de datos MEDLINE vía PubMed, Cochrane Database (ambas estrategias de búsqueda en el Anexo 1) y www.clinicaltrials.gov. Adicionalmente se realizó una búsqueda de guías de práctica clínica y evaluaciones de tecnologías sanitarias en las páginas web de la Asociación Americana del Corazón (AHA, por sus siglas en inglés), Colegio Americano de Cardiología (ACC, por sus siglas en inglés), Sociedad Cardiovascular Canadiense (CCS, por sus siglas en inglés), Sociedad Europea de Cardiología (ESC, por sus siglas en inglés), Red Escocesa de Guías Intercolegiales (SIGN, por sus siglas en inglés), Instituto Nacional de Salud y Cuidados de Excelencia (NICE, por sus siglas en inglés), Agencia Canadiense de Drogas y Tecnologías en Salud (CADTH, por sus siglas en inglés), Consorcio Escocés de Medicamentos (SMC, por sus siglas en inglés) y el Instituto de Revisiones Clínicas y Económicas (ICER, por sus siglas en inglés). Se priorizó la selección de guías de práctica clínica (GPC), evaluaciones de tecnología sanitaria (ETS), revisiones sistemáticas con meta-análisis y ensayos clínicos aleatorizados (ECA) que permitieran responder la pregunta PICO formulada. RESULTADOS: En la presente sinopsis se describe la evidencia disponible según el tipo de publicación, siguiendo lo indicado en los criterios de elegibilidad. CONCLUSIONES: En EsSalud, se cuenta con medicamentos de las tres clases necesarias para la terapia médica óptima de falla cardiaca de fracción de eyección reducida. Estos son los IECA (o ARA-II en caso de intolerancia a IECA), los beta-bloqueadores, y los antagonistas de aldosterona. El IETSI ya ha elaborado una evaluación de sacubitrilo/valsartán el cual se encuentra publicado como Dictamen Preliminar de Evaluación de Tecnología Sanitaria No. 15-SDEPFYOTS-DETS-IETSI-2018. En este dictamen no se aprueba el uso de esta tecnología sanitaria en el contexto de un paciente ambulatorio con falla cardiaca con fracción de eyección reducida, CF NYHA II-IV, recibiendo terapia médica óptima. El presente dictamen se realiza por tratarse, según los especialistas, de una población diferente al ser pacientes con falla cardiaca crónica con fracción de eyección reducida, sintomáticos (clase funcional NYHA II a IV), a pesar de recibir terapia médica óptima a dosis máxima tolerable por un tiempo mínimo de seis meses que se encuentren hospitalizados debido a falla cardiaca descompensada. Se seleccionaron y revisaron cuatro guías de práctica clínica (AHA/ACC 2017, CCS 2016, ESC 2016, SIGN-147) las cuales no son consistentes en sus recomendaciones a favor de sacubitrilo/valsartán. Por un lado, recomiendan su uso en remplazo de los IECA (o ARA-II en caso de intolerancia a IECA) por considerarlo de mayor beneficio. Por otro lado, recomiendan su uso sin preferencia como una alternativa a los IECA (o ARA-II en caso de intolerancia a IECA). Adicionalmente se incluyeron tres evaluaciones de tecnología sanitaria (NICE 2016, CADTH 2016 y ICER 2015) las cuales recomiendan el uso de sacubitrilo/valsartán en reemplazo de IECA (o ARA-II en caso de intolerancia a IECA). Tanto las guías de práctica clínica como las evaluaciones de tecnologías sanitarias se realizan en el contexto de un paciente ambulatorio, diferente a la población de la pregunta PICO del presente dictamen. No se encontraron revisiones sistemáticas ni ensayos clínicos que respondan la pregunta PICO del presente dictamen. A la fecha, la seguridad y tolerabilidad del uso de sacubitrilo/valsartán continúa siendo incierta. Existen varios estudios registrados en la página web clinicaltrials.gov que a pesar de haber culminado aun no tienen una publicación de sus resultados en una revista donde se realice una revisión por pares. Ante la falta de una opción terapéutica y de evidencia científica para la población de la pregunta PICO del presente dictamen, se acude a la opinión de médicos especialistas en cardiología. Los especialistas opinan que en el escenario de un paciente con falla cardiaca crónica de fracción de eyección reducida (FEVI<40%), clase funcional NYHA II a IV y que se encuentra hospitalizado por falla cardiaca descompensada a pesar de estar en terapia médica óptima a dosis máxima tolerable por un tiempo mínimo de seis meses, el uso de sacubitrilo/valsartán podría brindar beneficio clínico al paciente. Por lo expuesto, el Instituto de Evaluaciones de Tecnologías en Salud e Investigación - IETSI, aprueba el uso de sacubitrilo/valsartán en reemplazo de IECA (o ARA-II en caso de intolerancia a IECA) para el manejo de los pacientes con falla cardiaca crónica con fracción de eyección reducida de clase funcional NYHA II-IV, en terapia médica óptima por un tiempo mínimo de seis meses y que se encuentren hospitalizados por falla cardiaca descompensada. La vigencia del presente Dictamen Preliminar es de un año a partir de la fecha de publicación y está sujeta a la evaluación de los resultados obtenidos y de nueva evidencia que pueda surgir en el tiempo.

Change in renal function associated with drug treatment in heart failure: national guidance.

Inhibitors of the renin-angiotensin-aldosterone (RAAS) system are cornerstones of the management of patients with heart failure with reduced left ventricular ejection fraction (HFrEF). However, RAAS inhibitors may cause decline in renal function and/or hyperkalaemia, particularly during initiation and titration, intercurrent illness and during worsening of heart failure. There is very little evidence from clinical trials to guide the management of renal dysfunction. The Renal Association and British Society for Heart Failure have collaborated to describe the interactions between heart failure, RAAS inhibitors and renal dysfunction and give clear guidance on the use of RAAS inhibitors in patients with HFrEF. During initiation and titration of RAAS inhibitors, testing renal function is mandatory; a decline in renal function of 30% or more can be acceptable. During intercurrent illness, there is no evidence that stopping RAAS inhibitor is beneficial, but if potassium rises above 6.0 mmol/L, or creatinine rises more than 30%, RAAS inhibitors should be temporarily withheld. In patients with fluid retention, high doses of diuretic are needed and a decline in renal function is not an indication to reduce diuretic dose: if the patient remains congested, more diuretics are required. If a patient is hypovolaemic, diuretics should be stopped or withheld temporarily. Towards end of life, consider stopping RAAS inhibitors. RAAS inhibition has no known prognostic benefit in heart failure with preserved ejection fraction. Efforts should be made to initiate, titrate and maintain patients with HFrEF on RAAS inhibitor treatment, whether during intercurrent illness or worsening heart failure.

Effects of neprilysin-renin inhibition in comparison with neprilysin-angiotensin inhibition on the neurohumoral changes in rats with heart failure.

BACKGROUND: The activation of neurohumoral compensatory mechanisms is a common physiological phenomenon in heart failure in order to make up for a failing heart, which will usually have a deteriorating effect on overall health condition. Many medications, such as neprilysin and angiotensin inhibitors, have recently been introduced to remediate neurohumoral changes. This study was conducted to evaluate the efficacy of the sacubitril-aliskiren combination versus the sacubitril-ramipril combination in the treatment of neurohumoral changes in rats with experimentally induced heart failure. METHOD: Thirty Wister rats were randomly assigned into five groups each of six rats, the first group was the control group. Intraperitoneal isoprenaline injections of 5 mg/kg/day for 1 week were used to induce experimental models of heart failure in rats of the rest of experimental groups. The second group served as a positive control. Rats in the third, fourth, and fifth groups received oral daily dose of sacubitril 30 mg/kg/day, sacubitril-aliskiren 30,10 mg/kg/day, and sacubitril-ramipril 30/10 mg/kg/day respectively, for 2 weeks. RESULTS: Induction of heart failure in rats has significantly increased circulating NT-proBNP (980 ± 116.71 pg/ml), MMP9 (15.85 ± 0.57 ng/ml), troponin-I (3.09 ± 0.147 ng/ml), CK-MB (31.55 ± 1.69 ng/ml), renin (736 ± 45.8 pg/ml), urea (52.1 ± 1.57 mg/dl), and creatinine (0.92 ± 0.04 mg/dl). Significant decreases in glomerular filtration rate (7.031 ± 1.6 ml/hr./kg), urine flow (0.2761 ± 0.06 ml/h/kg), total solute excretion (0.11 ± 0.03 meq/m), and mean blood pressure (83.5 ± 2.6 mm hg) were seen in rats with heart failure. Rats treated with sacubitril combined with aliskiren or ramipril showed a statistically significant reduction of NT-proBNP, MMP9, troponin serum urea, and serum creatinine. Sacubitril-aliskiren or sacubitril-ramipril administration produced a significant increase in renin plasma level, total solute excretion, urine flow, and glomerular filtration rate. CONCLUSION: Sacubitril in combination with aliskiren or with ramipril effectively reduced plasma cardiac biomarkers, such as CK-MB, MMP9, and NT-proBNP, in rats with heart failure. Both combinations showed significant remediation of renal function through increasing GFR, urine flow, and total solute excretion, as well as reducing plasma level of renin. Net results revealed that the sacubitril-aliskiren combination has similar remediating effects on neurohumoral changes compared to the sacubitril-ramipril combination.