Cardiac arrhythmia (CA) is a group of heterogeneous diseases that often leads to abnormal pulse formation and conduction due to the mutation of potassium and sodium channels (1). Almost all antiarrhythmic drugs that are used to treat CA have arrhythmogenic effects. Amiodarone, a broad-spectrum antiarrhythmic drug, has limited long-term suitability in patients with heart failure (HF) due to its extracardiac toxicity (2). Ideal antiarrhythmic drugs can prevent serious arrhythmias, effectively control the ectopic rhythm, restore or maintain sinus rhythm, and have no toxic effects on hemodynamics and vital organs (3). The search continues for better antiarrhythmic drugs.

Sacubitril/valsartan (SV), as an angiotensin receptor-neprilysin inhibitor (ARNI), positively improves the imbalance between the rein-angiotensin-aldosterone-system (RAAS) and natriuretic peptide systems (4), and decreases rehospitalization rates and cardiovascular mortality of patients with HF compared with enalapril (5). More surprisingly, SV decreases the incidence of ventricular tachycardia, ventricular fibrillation, implantable cardioverter-defibrillator discharge, and SCD in patients with HF (6–8). Recent studies have shown that inflammation, fibrosis, and autoimmune mechanisms may also lead to electrical remodeling or ion channel dysfunction and promote arrhythmia (9–11). Drugs that inhibit myocardial remodeling (12), such as ARNI, may play antiarrhythmic roles by reducing the formation of ectopic impulses and reentry from the upstream mechanism (13). However, the controversy around SV remains: it increases the incidence of ventricular arrhythmias, especially in patients with ischemic heart disease (14, 15), although after adjusting the outcomes, the cardiovascular death caused by etiologies of HF such as ischemic, non-ischemic, and hypertensive cardiomyopathies are similar (16, 17). But, in men with ejection fraction of <35%, patients who recently took SV may be more prone to ventricular arrhythmias (18). The data between the antiarrhythmic effect of SV and the etiology, gender differences, and age categories of HF are still limited (4). Therefore, the relationship between SV and CA deserves further study. The question of whether SV has a direct or indirect antiarrhythmic effect or has a pro-arrhythmic effect, as with other antiarrhythmic drugs, remains to be answered.

Network pharmacology is a vital tool to indicate interactions between drugs and organisms. Drug pleiotropy may be considered in the context of interactions between the regulatory network of the drug target and the disease’ gene product. Thus, network analyses give insights into multiple actions of drugs and their mechanisms (19). This approach has been used successfully to clarify the multi-targeted regulation of Traditional Chinese Medicine for treating disease (20).

The current study investigates the molecular mechanisms by which SV ameliorates CA using the approach of network pharmacology. The resulting bioinformatics data may assist with basic research and enable the development of new drugs for CA.

The question addressed by the present study was whether SV has an antiarrhythmic or proarrhythmic effect in patients with HF. Using a network pharmacology approach, the current study reveals that SV, acting on core target genes (ACE, CAV1, AGT, REN, TP53, ADRB2, and ALB), has both direct and indirect effects during the treatment of CA.

The occurrence and maintenance of CA are usually mediated by ectopic activity and re-entry. The prolongation of the action potential/shortening of the effective refractory period and structural remodeling leads to slow and heterogeneous conduction, which provides the basis for reentrant arrhythmia. It was found that inhibiting the over-activation of RAAS reversed myocardial remodeling (23), reduced myocardial fibrosis and myocardial heterogeneous conduction. The formation of reentry and the occurrence of arrhythmia were both reduced (6, 7, 24), indicating an antiarrhythmic role. The current study showed that SV regulates ACE, CAV1, AGT, REN, and ADRB2 expression, inhibits tissue remodeling, and regulates vascular tension and volume by inhibiting the pathway of RAAS. In addition to myocardial remodeling, the remodeling of gap junctions is central to the generation and maintenance of arrhythmias. Gap junction remodeling leads to uncoupling of the myocardium, affects the conduction of the myocardial current, and generates arrhythmia. The SV may reduce the ventricular arrhythmias induced by myocardial hypertrophy by acting on the gap junction pathway (25, 26). Therefore, SV plays an indirect antiarrhythmic role by reversing myocardial and gap junction remodeling. Interestingly, angiotensin-converting enzyme inhibitor (ACEI) also reversed myocardial and gap remodeling, but did not reduce the incidence of SCD (27), suggesting that the antiarrhythmic effect of SV maybe also be related to neprilysin inhibition.

A decompensated state of HF is also represented by the over-activation of the SNS and is associated with poor prognosis, contributing to increased mortality risk. Neprilysin inhibition has been shown to activate the neuropeptide system, including that of atrial natriuretic peptide and brain natriuretic peptide, and synergistically inhibit SNS activity with valsartan (28). One pilot study showed that after taking SV for 2 months, the burst frequency and income of muscle sympathetic nerve activity decreased significantly, while heart rate and blood pressure did not change (29). It is by this strong antagonistic effect on the SNS that SV can reduce the incidence of SCD in patients with HF with reduced ejection fraction, an action that ACEI are unable to achieve (8). The β-adrenergic receptor antagonists are effective in reducing the damaging effects of increased SNS activity and produce significant mortality benefits for patients with HF. The ADRB2 gene encodes the β2-adrenergic receptor. Researchers have found that ADRB2 strongly increases localized RyR2-related cAMP levels during the over-activation of the SNS associated with cardiac hypertrophy or HF and increases ventricular arrhythmias (30). The ADRB2 also increases infiltration by pro-inflammatory macrophages, induces the production of IL-18, and sequentially stimulates the expression of connexin43 (Cx43) in fibroblasts in a paracrine manner, resulting in gap junction remodeling, myocardial fibrosis, and deterioration of cardiac function (31). The current findings that SV regulates ADRB2 expression suggest that the drug plays a direct antiarrhythmic role through pathways of hypertrophic cardiology and adrenergic signaling in cardiomyocytes.

Furthermore, the current study also found that SV regulates the levels of cav1 and TP53 and plays an antiarrhythmic role through the fluid shear stress and atherosclerosis pathway. Atrial fibrillation was associated with decreased CAV1 in right and left atria (p = 0.03); Loss of CAV1 leads to cSrc tyrosine kinase activation, gap junction remodeling, and ventricular arrhythmia, slowing left ventricular conduction velocity, and increasing ventricular arrhythmia inducibility (32). Further studies have shown that, when cardiac RAAS activity is enhanced, the dissociation of CAV1 from cSrc leads to cSrc activation, impaired gap junction function, and increased tendency toward ventricular arrhythmia and sudden cardiac death (33). These findings indicate that SV targets the regulation of CAV1 and reduces arrhythmia risk in heart disease associated with the activation of RAAS. Increased fibrosis and activated TP53 signaling were demonstrated in heart tissue from patients with dilated cardiomyopathy disease with ventricular tachycardia (34).

Any molecular mechanisms, where SV promotes arrhythmia, were not found in the current study. Clinical reports have indicated that SV can increase the incidence of ventricular arrhythmias in patients with HF (8, 14), but with short follow-up times and small sample sizes. Etiology, gender differences, and inclusion of high-risk patients may also affect the results (4). Further basic and clinical research into SV is needed to clarify whether the drug has proarrhythmic effects.

In summary, a network pharmacological approach was used to demonstrate that SV acted on seven core target genes (ACE, CAV1, AGT, REN, TP53, ADRB2, and ALB) and reversed myocardial and gap junction remodeling improved the imbalance of RAAS, SNS, and neuropeptide system and had an indirect and direct antiarrhythmic effect. The most enriched pathways were renin secretion, renin-angiotensin system, hypertrophic cardiomyopathy, fluid shear stress and atherosclerosis, and adrenergic signaling in cardiomyocytes. The current study may further guide the basic and clinical investigations on the antiarrhythmic or proarrhythmic effects of SV on CA and contribute to the discovery of ideal antiarrhythmic drugs.

We acknowledge some limitations of the current study. Firstly, SV was decomposed into two separate components, Sacubitril and Valsartan, and the combination was not studied leading to some potential experimental deviations by comparison with the clinically administered formula. Secondly, targets for SV with potential antiarrhythmic effects were collected using public databases, which may lead to some inaccuracies. Thirdly, the core targets identified in this study require further validation via both basic scientific and clinical studies.

The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/supplementary material.

CJ designed and performed the research. YZ wrote and revised the manuscript. SR and ST analyzed the public data and revised the manuscript. All authors read and approved the final manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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