USE OF THROMBOXANE A2 ANTAGONISTS FOR THE MANUFACTURE OF A MEDICAMENT FOR IMPROVING POST-ISCHEMIC MYOCARDIAL DYSFUNCTION

Abstract: A method is provided for improving post-ischemic myocardial dysfunction such as contractile dysfunction or reperfusion injury by administering a thromboxane A₂ antagonist before, during or immediately after an ischemic attack.

Description: The present invention relates to the use of a thromboxane A₂ antagonist also referred to as a thromboxane A₂ receptor antagonist for the manufacture of a medicament to enhance the recovery of heart function, in a method for improving post-ischemic myocardial dysfunction in mammalian species. Blood flow reductions in the heart can result in dysfunction of this organ and cell death if the flow reduction is severe enough. Restoration of coronary blood flow early during a heart attack is becoming a clinical reality with the advent and improvements in thrombolytic, mechanical, and surgical interventions. While early restoration of blood flow, for example, by thrombolysis or following transient ischemia, can prevent or mitigate the degree of cell death (infarction) occurring, reperfusion can still result in some degree of cardiac dysfunction or cell death (also referred to as stunned myocardia). Thus, it would be of great clinical value to find a means to preserve reperfusion function of the heart. Thromboxane A₂ (TXA) which is released from the heart during reperfusion is thought to have physiological effects that may adversely influence myocardial performance, namely, TXA contributes to post ischemic contractile dysfunction, Hoeft, A., et al., "Preservation of myocardium in transient ischemia by the thromboxane synthetase inhibitor." UK-38,485. Res. Exp. Med. 1986; 186:35-46, and Schror, K., et al."Treatment of acute myocardial ischemia with a selective antagonist of thromboxane receptors. (BM 13,177)" Br. J. Pharmacol. 1986; 87:631-7. Hoeft et al, supra, and Schror et al, supra, demonstrate the ability of TXA inhibitors or antagonists to reduce the severity of ischemia in some experimental models, though the physiological mechanisms of action of these compounds on post-ischemic recovery of function are still unknown. For instance, it is thought that TXA is released during ischemia as well as during reperfusion and thus TXA antagonists may be working during coronary occlusion and/or during reperfusion, Schmitz, J. M., et al., "Vascular prostaglandin and thromboxane production in a canine model of myocardial ischemia." Circ. Res. 1985 57:223-31, Michael, L. H., et al., "Myocardial ischemia: platelet and thromboxane concentrations in cardiac lymph and the effects of ibuprofen and prostacyclin." Circ. Res. 1986; 59:49-55. In accordance with the present invention, there is provided the use of a thromboxane A₂ antagonist for manufacture of a medicament for improving post-ischemic myocardial dysfunction in mammalian species, to reduce or eliminate reperfusion injury, wherein the medicament is for administration only during reperfusion. This use renders possible the mitigation of the post-ischemic adverse effects of thromboxane on heart function during periods of myocardial occlusion and reperfusion. The term "reperfusion" is employed herein to refer to release of occlusion and resumption of blood flow. It has been found that the thromboxane A₂ antagonist improves post-ischemic performance of the heart by improving post-ischemic contractile function when administered only during the reperfusion period. Such improvement in post-ischemic performance of the heart is evidenced by decreased contractile dysfunction and decrease in tissue necrosis. Thromboxane A₂ antagonists which may be employed herein include the 7-oxabicycloheptane and 7-oxabicycloheptene compounds disclosed in U.S. Patent No. 4,537,981 to Snitman et al, especially, [1S-[1α,2β(5Z),3β(1E,3R,4S),4α]]-7-[3-(3-hydroxy-4-phenyl-1-pentenyl)-7-oxabicyclo[2.2.1]hept-2-yl]-5-heptenoic acid; the 7-oxabicycloheptane substituted amino-prostaglandin analogs disclosed in U. S. Patent No. 4,416,896 to Nakane et al., especially, [1S-[1α,2β(5Z),3β,4α]]-7-[3-[[2-(phenylamino)carbonyl]hydrazino]methyl]-7-oxabicyclo[2.2.1]hept-2-yl]-5-heptenoic acid; the 7-oxabicycloheptane substituted diamide prostaglandin analogs disclosed in U. S. Patent No. 4,663,336 to Nakane et al, especially, [1S-[1β,2α(5Z),3α,4β]]-7-[3-[[[[(1-oxoheptyl)amino]acetyl]amino]methyl]-7-oxabicyclo[2.2.1]hept-2-yl]-5-heptenoic acid and the corresponding tetrazole, and [1S-[1α,2β(Z),3β,4α]]-7-[3-[[[[(4-cyclohexyl-1-oxobutyl)amino]acetyl]amino]methyl]-7-oxabicyclo[2.2.1]hept-2-yl]-5-heptenoic acid; the phenoxyalkyl carboxylic acids disclosed in U. S. Patent No. 4,258,058 to Witte et al, especially 4-[2-(benzenesulfamido)ethyl]phenoxyacetic acid, (BM 13,177 - Boehringer Mannheim), the sulphonamidophenyl carboxylic acids disclosed in U. S. Patent No. 4,443,477 to Witte et al, especially 4-[2-(4-chlorobenzenesulfonamido)ethyl]phenylacetic acid, (BM 13,505, Boehringer Mannheim) the arylthioalkylphenyl carboxylic acids disclosed in U. S. Patent No. 4,752,616, especially 4-(3-((4-chlorophenyl)sulfonyl)propyl)benzeneacetic acid. Other examples of thromboxane A₂ inhibitors suitable for use herein include, but are not limited to (E)-5-[[[(pyridinyl)[3-(trifluoromethyl)phenyl]methylene]amino]oxy]pentanoic acid also referred to as R68,070 - Janssen Research Laboratories, 3-[1-(4-chlorophenylmethyl)-5-fluoro-3-methylindol-2-yl]-2,2-dimethylpropanoic acid [(L-655240 Merck-Frosst) Eur. J. Pharmacol. 135(2):193, 17 Mar. 87], 5(Z)-7-([2,4,5-cis]-4-(2-hydroxyphenyl)-2-trifluoromethyl-1,3-dioxan-5-yl)heptenoic acid (ICI 185282, Brit. J. Pharmacol 90 (Proc. Suppl):228 P-Abs., Mar. 87), 5(Z)-7-[2,2-dimethyl-4-phenyl-1,3-dioxan-cis-5-yl]-heptenoic acid (ICI 159995, Brit. J. Pharmacol. 86 (Proc. Suppl):808 P-Abs., Dec. 85), N,N′-bis[7-(3-chlorobenzeneaminosulfonyl)-1,2,3,4-tetrahydro-isoquinolyl]disulfonylimide (SKF 88046, Pharmacologist 25(3):116 Abs, 117 Abs, Aug. 83), [1α(Z)-2β,5α]-(+)-7-[5-[[(1,1'-biphenyl)-4-yl]methoxy]-2-(4-morpholinyl)-3-oxocyclopentyl]-4-heptenoic acid (AH 23848 - Glaxo, Circulation 72(6):1208, Dec. 85, levallorphan allyl bromide (CM 32,191, Sanofi, Life Sci. 31 (20 21):2261, 15 Nov. 82), (Z,2-endo-3-oxo)-7-(3-acetyl-2-bicyclo[2.2.1]heptyl-5-hepta-3Z-enoic acid, 4-phenylthiosemicarbazone (EP092 - Univ. Edinburgh, Brit, J. Pharmacol. 84(3):595, Mar. 85). In carrying out the use of the present invention, the thromboxane A₂ antagonist is administered to mammalian species, such as monkeys, dogs, cats, rats and humans, during the period of reperfusion. Although the thromboxane A₂ antagonist may be administered systemically, such as orally or parenterally, it is preferred that the thromboxane A₂ antagonist be administered locally to the coronary arteries by catheter such as by arterial angiography or intracoronary injection. With regard to dosage of thromboxane A₂ antagonist, where the drug is administered by arterial angiography or intracoronary injection, from 0.1 to 30 mg/kg/treatment and preferably from 0.5 to 25 mg/kg/treatment will be employed. The number of treatments will depend upon the length of the ischemic attack and the progress of reperfusion to achieve normal heart function. Usually, from 1 to 5 treatments per day will be required for as long as contractile dysfunction continues. Where the thromboxane A₂ antagonist is to be administered by angiography or intracoronary injection, it will be formulated in a conventional vehicle, such as distilled water, saline, Ringer's solution, or other conventional carriers. The thromboxane A₂ antagonist may also be incorporated in a conventional dosage form, such as a tablet, capsule, elixir or injectable. The above dosage forms will also include the necessary carrier material, excipient, lubricant, buffer, antibacterial, bulking agent (such as mannitol) and anti-oxidants (ascorbic acid of sodium bisulfite). Oral dosage forms are preferred, although parenteral forms are quite satisfactory as well. With regard to such systemic formulations, single or divided doses of from 5 to 2500 mg, preferably from about 10 to 2000 mg/one to four times daily, may be administered in systemic dosage forms as described above for a period sufficient to restore normal heart function. Figure 1 is a graph of the effect of iv thromboxane A₂ antagonist (SQ 29,548) on myocardial stunning; and Figure 2 is a graph of the effect of thromboxane A₂ antagonist (SQ 29,548) given 1 minute before reperfusion on stunned myocardium. The following Examples represent preferred embodiments of the present invention. Example 1 An injectable solution for use in administering thromboxane A₂ antagonist by by intracoronary injection, by arterial angiography or intravenously is produced as follows: [1S-[1α,2β(5Z),3β,4α]]-7-[3-[[2-(phenylamino)carbonyl]hydrazino]methyl]-7-oxabicyclo[2.2.1]hept-2-yl]-5-heptenoic acid (SQ 29,548) 2500 mg Methyl paraben 5 mg Propyl paraben 1 mg Sodium chloride 25 g Water for injection qs. 5 l. The thromboxane A₂ antagonist, preservatives and sodium chloride are dissolved in 3 liters of water for injection and then the volume is brought up to 5 liters. The solution is filtered through a sterile filter and aseptically filled into presterilized vials which are then closed with presterilized rubber closures. Each vial contains a concentration of 75 mg of active ingredient per 150 ml of solution. Example 2 An injectable for use in improving post-ischemic contractile dysfunction is prepared as described in Example 1 except that the thromboxane A₂ antagonist employed is the phenoxyalkyl carboxylic acid 4-[2-(benzenesulfamido)ethyl]phenoxyacetic acid, disclosed in U. S. Patent No. 4,258,058. Example 3 An injectable solution for use in administering thromboxane A₂ antagonist by intracoronary injection, by arterial angiography or intravenously containing [1S-[1β,2α(5Z),3α,4β]]-7-[3-[[[[(1-oxoheptyl)amino]acetyl]amino]methyl]-7-oxabicyclo[2.2.1]hept-2-yl]-5-heptenoic acid (SQ 30,741) as the thromboxane A₂ antagonist is prepared as described in Example 1. Example 4 An injectable for use in improving post-ischemic contractile dysfunction is prepared as described in Example 1 except that the thromboxane A₂ antagonist employed is [1S-[1<α,2<β(Z),3<β,4<α]]-7-[3-[[[[(4-cyclohexyl-1-oxobutyl)amino]acetyl]amino]methyl]-7-oxabicyclo[2.2.1]hept-2-yl]-5-heptenoic acid; Example 5 A thromboxane A₂ antagonist formulation suitable for oral administration is set out below. 1000 tablets each containing 400 mg of thromboxane A₂ antagonist were produced from the following ingredients. [1S-[1β,2α(5Z),3α,4β]]-7-[3-[[[[(1-Oxoheptyl)amino]acetyl]amino]methyl]-7-oxabicyclo[2.2.1]hept-2-yl]-5-heptenoic acid (SQ 30,741) 400 g Corn starch 50 g Gelatin 7.5 g Avicel (microcrystalline cellulose) 25 g Magnesium stearate 2.5 g The thromboxane antagonist and corn starch are admixed with an aqueous solution of the gelatin. The mixture is dried and ground to a fine powder. The Avicel and then the magnesium stearate are admixed with the granulation. This is then compressed in a tablet to form 1000 tablets each containing 400 mg of active ingredient. Example 6 The following experiment was conducted to determine the effect of the TXA antagonist, [1S,-[1α,2β(5Z),3β,4α]]-7-[3-[[2-(phenylamino)carbonyl]hydrazino]methyl]-7-oxabicyclo[2.2.1]hept-2-yl]-5-heptenoic acid (also referred to as SQ 29,548), on post-ischemic contractile function during (1) the coronary occlusion and reperfusion periods (prior art) and (2) during reperfusion alone (invention). Methods Adult mongrel dogs (10-15 mg) were anesthetized using pentobarbital sodium (30 mg/kg, i.v.). Aortic blood pressure was measured using a Mikro-tip catheter transducer (Millar Instruments) inserted into the right carotid artery. The right femoral artery was catheterized for collection of blood for measurement of blood gases. A left femoral venous catheter was inserted for drug infusion and supplemental anesthesia. Each animal was intubated and placed on artificial respiration such that eucapnia was maintained. They were then subjected to a left thoracotomy and the pericardium was formed into a cradle. The left anterior descending coronary artery (LAD) was isolated proximal to its first branch and a silk ligature was placed around it. In animals to be given intracoronary (i.c.) injections, a bent 27 gauge needle with an attached catheter was inserted into the LAD distal to the ligature. A left atrial catheter was implanted for injection of dye (determination of area at risk at the end of the experiment). Segmental shortening in the LAD perfused region was determined using ultrasonic piezoelectric crystals implanted into the subendocardium of this region. The crystals in each pair were placed approximately 10 mm apart. At this time, the animals were divided into 4 groups: 1. Animals given i.v. saline (n=9) starting 15 min before LAD occlusion. 2. Animals given the TXA antagonist SQ 29,548 (0.20 mg/kg + 0.20 mg/kg/h, n=7) i.v. starting 15 minutes before LAD occlusion. 3. Animals given i.c. SQ 29,548 (0.20 mg/kg + 0.2 mg/kg/h, n=7) starting 1 minute before reperfusion. 4. Animals given i.c. saline starting 1 minute before reperfusion (n=11). The subject TXA antagonist is a potent and selective TXA/prostaglandin endoperoxide antagonist (SQ 29,548) as previously described by Ogletree, M. L., et. al., "Pharmacological actions of SQ 29,548, a novel selective thromboxane antagonist," J. Pharmacol. Exp. Ther. 1985; 234:435-41. The dose of the TXA antagonist used has been shown to be effective in blocking >99% of TXA receptors, Grover, G. J., et al., "Effect of the thromboxane receptor antagonist SQ 29,548 on infarct size in dogs." Circulation 1986; 74 (Suppl II): 348 (Abstract). The LAD was occluded via the silk ligature for 15 minutes at which time the occlusion was released and reperfusion instituted for 5 hours. Hemodynamic and segment shortening data were collected before occlusion, during occlusion, and throughout the reperfusion period. At the end of the experiment, the area at risk was determined, by injection of patent blue violet dye into the left atrial catheter while the LAD was being perfused with Ringer's lactate at the animals' existing blood pressure. The hearts were then removed and the area at risk was then determined by tracing the hearts on transparencies and calculating the areas of interest using planimetry. The segment shortening data were normalized as previously described by Theroux, P., et al., "Regional myocardial function in the conscious dog during acute coronary occlusion and responses to morphine, propranolol, nitroglycerin and lidocaine." Circulation 1976; 53:302-14. Shimshak, T.M., et al. "Recovery of contractile function in post-ischemic reperfused myocardium of conscious dogs: influence of nicorandil, a new antianginal agent." Cardiovasc. Res. 1986; 20:621-6. End diastolic length (EDL) as well as end systolic length (ESL) were determined and the percentage segment shortening (%SS) was calculated from the equation: %SS=(EDL - ESL)/EDL . All data are presented as mean ± SE. Between treatment hemodynamic comparisons were made using a one-way analysis of variance and multiple comparisons were determined using the Newman-Keuls test. Segment shortening was expressed as a percent of initial baseline values and between treatment comparisons were made using the Kruskal-Wallis test for nonparametric data. A value of p<0.05 was accepted as significant. Results Hemodynamic data for i.v. saline- and TXA antagonist (SQ 29,458)-treated animals are shown on Table 1. Arterial blood pressure and heart rate were similar under baseline conditions for both groups shown on this table and did not change during the experiment. Arterial blood gases were maintained within the normal range for dogs throughout the experiment. The effect of i.v. SQ 29,548 (0.20 mg/kg + 0.20 mg/kg/h, n=7) pretreatment (given 15 minutes before LAD occlusion) on segmental shortening during occlusion and reperfusion is shown on Fig. 1. The segmental shortening in the LAD region is expressed as a percent of baseline, pre-treatment (pre-occlusion) values in this figure. Occlusion of the LAD resulted in a marked systolic bulging in both groups. This occlusion value was measured 1 minute before reperfusion. Upon reperfusion, segmental shortening immediately returned towards baseline values in both drug- and saline-treated animals. At 5-15 minutes, function was again markedly reduced such that in saline-treated animals, segmental shortening was nearly nonexistent. In animals treated with SQ 29,548, contractile function was significantly improved compared with saline-treated animals starting at 5 minute post-reperfusion. This improved function was observed at most of the reperfusion times measured. At 5 hours post-reperfusion, shortening returned to 25% of baseline values in saline-treated animals, but returned to approximately 60% in drug-treated animals. While not shown on Figure 1, segmental shortening was measured during drug or saline treatment immediately before LAD occlusion and found that neither drug nor saline treatment had any effect on segmental shortening. The area at risk as a percent of the left ventricle was found to be nearly identical in both saline- and SQ 29,548-treated groups (30±2% and 30±8%, respectively). The crystals were always found to be in the center of the area at risk. As seen, Figure 1 shows use of Q 29,548 resulted in significant (p, <0.05) improvements in reperfusion function. The hemodynamic data for animals treated with i.c. saline or SQ 29,548 just before reperfusion are shown on Table 2. Baseline pressure and heart rate values were similar for both groups and did not change throughout the experiment. Arterial blood gases were maintained within the normal range for dogs throughout the experiment. Segmental shortening data (expressed as a % of the baseline values) for i.c. saline- and SQ 29,548-treated animals (0.20 mg/kg + 0.20 mg/kg/h, n=7 given 1 minute before reperfusion) are shown in Figure 2 . LAD occlusion again resulted in marked systolic bulging in both groups when measured 1 minute before reperfusion (immediately before drug or saline infusion). Upon reperfusion, shortening immediately returned towards baseline values in both groups. By 5 minutes post-reperfusion, function in saline-treated animals began to decrease again until at 15 minute post-reperfusion, segmental shortening was approximately 15% of baseline values. Function was better maintained in SQ 29,548-treated animals up until 10 minutes post-reperfusion at which time function dropped off markedly to values that were only slightly and nonsignificantly higher than the respective saline values. This trend continued until 3 hours post-reperfusion when segmental shortening in the LAD region began to rapidly improve in SQ 29,548-treated animals compared with saline values. This trend continued up to the end of the experiment where shortening in the affected region returned to approximately 70% of baseline values. At this time, function had returned to approximately 20% of baseline in saline-treated animals. The area at risk as a percent of the left ventricle was found to be similar in both i.c. saline- and SQ 29,548-treated groups (30±7% and 29±2% respectively). The crystals were always found to be in the center of the area at risk. As seen in Figure 2, with the above dosing regime, use of SQ 29,548 resulted in significant improvements (*, p<0.05) in reperfusion at several of the time points measured. Discussion Brief coronary occlusions of insufficient severity to result in tissue necrosis can still, upon reperfusion, result in significant contractile dysfunction lasting for hours or days (myocardial stunning), Pagani, M., et al., "Initial myocardial adjustments to brief periods of ischemia and reperfusion in the conscious dog," Circ. Res. 1978; 43:83-92; Weiner, J. M., et al. . "Persistence of myocardial injury following brief periods of coronary occlusion.", Cardiovasc. Res. 1976; 10:678-86. The exact mechanism for this hypokinesia is still vague, though some aspects of reperfusion injury may play a deleterious role. In the present study, the role of TXA release on myocardial stunning was determined by using a selective TXA receptor antagonist, SQ 29,548. The dose of SQ 29,548 used in this study has been found to block >99% of the TXA receptors as measured by inhibition of the renal and mesenteric arterial constrictor response to the TXA mimetic U-46619, Grover et al supra. The model of stunned myocardium used in the present study has been used extensively before and has been found to result in a reproducible post-ischemic dysfunction, Heyndrickx, G. R., et al., "Regional myocardial functional and electrophysiological alterations after brief coronary artery occlusion in conscious dogs," J. Clin. Invest. 1975; 56:978-85; Heyndrickx, G. R., et al "Depression of regional blood flow and wall thickening after brief coronary occlusion," Am. J. Physiol. 1978; 234:H653-9. As previously shown, occlusion of the LAD in the present study resulted in passive bulging during systole in all groups to a similar degree. Immediately upon reperfusion, contractile function markedly increased in saline-treated animals, but just as quickly decreased again. Function in the affected region then slowly improved, but never returned to baseline values in the 5 hours reperfusion period that was followed in this study. Treatment with SQ 29,548 resulted in a significant improvement in post-ischemic contractile function. Pre-treatment with the drug caused an improved function at most reperfusion times measured (though this study alone does not tell if the SQ 29,548 is working during the occlusion or reperfusion times). Previous studies have indicated that antagonism of TXA seems to afford a direct cardioprotective effect during occlusion, Schror et al, supra, but it was still of interest to determine if SQ 29,548 could have some or all of its protective effects during reperfusion period. When infused 1 minute before reperfusion, some improvement in function particularly during the later times measured was observed. It appears that some of the beneficial effects of SQ 29,548 on recovery of function occur during the reperfusion period, but this improvement was not as marked as that seen with pre-treatment. This indicates that SQ 29,548 can exert salutory effects during the occlusion and reperfusion periods. Summary Selective TXA receptor antagonists appear to improve the post-ischemic performance of the heart. This was tested using the TXA antagonist, Q 29,548, in a model of ischemia and subsequent reperfusion. The return of function during reperfusion in these hearts was measured and it was found that SQ 29,548 markedly enhanced the recovery of heart function not only when given in a known manner during both the coronary occlusion and reperfusion periods but also when given only during the reperfusion period.

Claims: The use of a thromboxane A₂ antagonist for manufacture of a medicament for improving post-ischemic myocardial dysfunction in a mammalian species, to reduce or eliminate reperfusion injury wherein the medicament is for administration only during reperfusion. The use as defined in Claim 1 wherein the thromboxane A₂ antagonist is a phenoxyalkyl carboxylic acid, a sulfonamidophenyl carboxylic acid, or an arylthioalkylphenyl carboxylic acid. The use as defined in Claim 1 wherein the thromboxane A₂ antagonist is [1S-[1α,2β(5Z),3β(1E,3R,4S),4α]]-7-[3-(3-hydroxy-4-phenyl-1-pentenyl)-7-oxabicyclo[2.2.1]hept-2-yl]-5-heptenoic acid; [1S-[1β,2α(5Z),3α,4β]]-7-[3-[[[[(1-oxoheptyl)amino]acetyl]amino]methyl]-7-oxabicyclo[2.2.1]hept-2-yl]-5-heptenoic acid or the corresponding tetrazole; [1S-[1α,2β(Z),3β,4α]]-7-[3-[[[[(4-cyclohexyl-1-oxobutyl)amino]acetyl]amino]methyl]-7-oxabicyclo[2.2.1]hept-2-yl]-5-heptenoic acid; [1S-[1α,2β(5Z),3β,4α]]-7-[3-[[2-(phenylamino)carbonyl]hydrazino]methyl]-7-oxanbicyclo[2.2.1]hept-2-yl]-5-heptenoic acid; 4-(3-((4-chlorophenyl)sulfonyl)propyl)benzene acetic acid; 4-[2-(benzenesulfamido)ethyl]phenoxyacetic acid; or 4-[2-(4-chloronenzenesulfonamido)ethyl]phenylacetic acid.

Inventors: FULMOR, IRVIN EDGAR III, GROVER, GARY JAMES
Applicants: E.R. SQUIBB & SONS, INC.
Application year: 1988
Main classification: A61K31
IPC codes: A61P9, A61K31, C07D493, A61K45