Do Dipeptidyl Peptidase-4 Inhibitors Cause Heart Failure Events by Promoting Adrenergically-Mediated Cardiotoxicity? Clues from Laboratory Models and Clinical Trials
Rationale: Dipeptidyl peptidase-4 (DPP-4) inhibitors have increased the risk of heart failure events in both randomized clinical trials and observational studies, but the mechanisms that underlie their deleterious effect remain to be elucidated. Previous work has implicated a role of these drugs to promote cardiac fibrosis.
Objective: This paper postulates that DPP-4 inhibitors increase the risk of heart failure events by activating the sympathetic nervous system to stimulate cardiomyocyte cell death, and it crystallizes the findings from both experimental studies and clinical trials that support the hypothesis.
Methods and Results: Inhibition of DPP-4 not only potentiates the actions of glucagon-like peptide-1 (which can increase myocardial cyclic AMP), but it also potentiates the actions of stromal cell-derived factor-1 (SDF-1), neuropeptide Y and substance P to activate the sympathetic nervous system and stimulate beta-adrenergic receptors to cause cardiomyocyte apoptosis, presumably through a Ca++/calmodulin-dependent protein kinase II pathway. An action of SDF-1 to interfere with cyclic AMP and protein kinase A signaling may account for the absence of a clinically overt positive chronotropic effect. This conceptual framework is supported by the apparent ability of beta-blocking drugs to attenuate the increased risk of DPP-4 inhibitors in a large-scale clinical trial.
Conclusions: Sympathetic activation may explain the increased risk of heart failure produced by DPP-4 inhibitors. The proposed mechanism has major implications for clinical care, since in the treatment of patients with type 2 diabetes, DPP-4 inhibitors are widely prescribed, but beta-blockers are underutilized because of fears that they might mask hypoglycemia.
- Dipeptidyl peptidase 4 inhibitors
- Stromal cell-derived factor-1
- neuropeptides/leptin/neuropeptide Y
- growth substances
- sympathetic nervous system
- heart failure
- diabetic cardiomyopathy
- adrenergic stimulation
- Received January 4, 2018.
- Revision received January 30, 2018.
- Accepted February 6, 2018.
Circulation Research is published on behalf of the American Heart Association, Inc., by Wolters Kluwer. This is an open access article under the terms of the Creative Commons Attribution Non-Commercial License (http://creative commons.org/licenses/by-nc/3.0/), which permits use, distribution, and reproduction in any medium, provided that the original work is properly cited and is not used for commercial purposes.