Istaroxime metabolite PST3093 selectively stimulates SERCA2a and reverses disease-induced changes in cardiac function

Heart failure (HF) therapeutic toolkit would strongly benefit from the availability of ino-lusitropic agents with a favourable pharmacodynamics and safety profile. PST3093 is the main metabolite of istaroxime, an agent combining Na+/K+ pump inhibition and SERCA2a stimulation, shown by phase 2 trials to be promising in the acute setting. PST3093 half-life is substantially longer than that of istaroxime; therefore, if it retained the effects of the parent compound, it would allow to exploit istaroxime pharmacodynamics in chronic treatment. We studied PST3093 for its effects on SERCA2a and Na+/K+ ATPase activities, Ca2+ dynamics in isolated myocytes and hemodynamic effects in an in-vivo rat model of diabetic (streptozotocin (STZ)-induced) cardiomyopathy. At variance with its parent compound, PST3093 is a “selective” (i.e. devoid of Na+/K+ pump inhibition) SERCA2a activator. In in-vivo echocardiographic assessment, PST3093 improved overall cardiac performance (e.g. stroke volume) without decreasing heart rate, and reversed most STZ-induced abnormalities. Modulation of both systolic and diastolic indexes contributed to the improvement. For i.v. administration, PST3093 toxicity was considerably lower than that of istaroxime and its evaluation against 50 targets commonly involved in cardiac and extracardiac side-effects, failed to reveal significant interactions. PST3093 is a “selective” SERCA2a activator, the prototype of a novel pharmacodynamic category with a potential in the ino-lusitropic approach to HF, particularly with prevailing diastolic dysfunction. While PST3093 may actually contribute to the proven clinical efficacy of istaroxime, its pharmacodynamics are peculiar and its pharmacokinetics are suitable for chronic administration.