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Monzo L, Kovar J, Borlaug BA, Benes J, Kotrc M, Kroupova K, Jabor A, Franekova J, Melenovsky V. Circulating beta-hydroxybutyrate levels in advanced heart failure with reduced ejection fraction: Determinants and prognostic impact. Eur J Heart Fail 2024. [PMID: 38853653 DOI: 10.1002/ejhf.3324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 06/11/2024] Open
Abstract
AIMS Patients with heart failure (HF) display metabolic alterations, including heightened ketogenesis, resulting in increased beta-hydroxybutyrate (β-OHB) formation. We aimed to investigate the determinants and prognostic impact of circulating β-OHB levels in patients with advanced HF and reduced ejection fraction (HFrEF). METHODS AND RESULTS A total of 867 patients with advanced HFrEF (age 57 ± 11 years, 83% male, 45% diabetic, 60% New York Heart Association class III), underwent clinical and echocardiographic examination, circulating metabolite assessment, and right heart catheterization (n = 383). The median β-OHB level was 64 (interquartile range [IQR] 33-161) μmol/L (normal 0-74 μmol/L). β-OHB levels correlated with increased markers of lipolysis (free fatty acids [FFA]), higher natriuretic peptides, worse pulmonary haemodynamics, and lower humoral regulators of ketogenesis (insulin/glucagon ratio). During a median follow-up of 1126 (IQR 410-1781) days, there were 512 composite events, including 324 deaths, 81 left ventricular assist device implantations and 107 urgent cardiac transplantations. In univariable Cox regression, increased β-OHB levels (T3 vs. T1: hazard ratio [HR] 1.39, 95% confidence interval [CI] 1.13-1.72, p = 0.002) and elevated FFA levels (T3 vs. T1: HR 1.39, 95% CI 1.09-1.79, p = 0.008) were both predictors of a worse prognosis. In multivariable Cox analysis evaluating the simultaneous associations of FFA and β-OHB levels with outcomes, only FFA levels remained significantly associated with adverse outcomes. CONCLUSIONS In patients with advanced HFrEF, increased plasma β-OHB correlate with FFA levels, worse right ventricular function, greater neurohormonal activation and other markers of HF severity. The association between plasma β-OHB and adverse outcomes is eliminated after accounting for FFA levels, suggesting that increased β-OHB is a consequence reflecting heightened lipolytic state, rather than a cause of worsening HF.
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Affiliation(s)
- Luca Monzo
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433 and Inserm U1116, CHRU Nancy, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Jan Kovar
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Barry A Borlaug
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Jan Benes
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Martin Kotrc
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Katerina Kroupova
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Antonin Jabor
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Janka Franekova
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Vojtech Melenovsky
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
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2
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Christensen KH, Nielsen RR, Schou M, Gustafsson I, Jorsal A, Flyvbjerg A, Tarnow L, Bøtker HE, Kistorp C, Johannsen M, Møller N, Wiggers H. Circulating 3-hydroxy butyrate predicts mortality in patients with chronic heart failure with reduced ejection fraction. ESC Heart Fail 2024; 11:837-845. [PMID: 38196294 DOI: 10.1002/ehf2.14476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/13/2023] [Accepted: 07/02/2023] [Indexed: 01/11/2024] Open
Abstract
AIMS In patients with chronic heart failure with reduced ejection fraction (HFrEF), myocardial ketone metabolism is increased and short-term treatment with the ketone body 3-hydroxy butyrate (3-OHB) has beneficial haemodynamic effects. In patients with HFrEF, we investigated whether the level of circulating 3-OHB predicted all-cause mortality and sought to identify correlations between patient characteristics and circulating 3-OHB levels. METHODS AND RESULTS We conducted a cohort study in 218 patients with HFrEF. Plasma 3-OHB levels were measured using high-performance liquid chromatography tandem mass spectrometry. Data on all-cause mortality were obtained by reviewing the patients' medical records, which are linked to the national 'Central Person Registry' that registers the timing of all deaths in the country. Mean left ventricular ejection fraction was 35 ± 8.6%, mean age was 67 ± 10 years, 54% were New York Heart Association II, and 27% had type 2 diabetes mellitus. Median follow-up time was 7.3 (interquartile range 6.3-8.4) years. We observed large variations in 3-OHB levels between patients (median 59 μM, range: 14-694 μM). Patients with 3-OHB levels above the median displayed a markedly increased risk of death compared with those with low levels {hazard ratio [HR]: 2.1 [95% confidence interval (CI): 1.3-3.5], P = 0.003}. In a multivariate analysis, 3-OHB predicted mortality independently of known chronic heart failure risk factors [HR: 1.004 (95% CI: 1.001-1.007), P = 0.02] and with a similar statistical strength as N-terminal pro-brain natriuretic peptide (NT-proBNP) [HR: 1.0005 (95% CI: 1.000-1.001), P = 0.02]. For every 100 μmol increase in plasma 3-OHB, the hazard of death increased by 49%. The following factors significantly predicted 3-OHB levels in the univariate analysis: free fatty acids (FFAs) [β: 238 (95% CI: 185-292), P < 0.0001], age [β: 2.43 (95% CI: 1.14-3.72), P < 0.0001], plasma insulin {β: -0.28 [95% CI: -0.54-(-0.02)], P = 0.036}, body mass index {β: -3.15 [95% CI: -5.26-(-0.05)], P = 0.046}, diabetes [β: 44.49 (95% CI: 14.84-74.14), P = 0.003], glycosylated haemoglobin [β: 1.92 (95% CI: 0.24-3.59), P = 0.025], New York Heart Association class [β: 26.86 (95% CI: 5.99-47.72), P = 0.012], and NT-proBNP [β: 0.03 (95% CI: 0.01-0.04), P = 0.001]. In a multivariate analysis, only FFAs predicted 3-OHB levels [β: 216 (95% CI: 165-268), P > 0.001]. CONCLUSIONS In patients with HFrEF, circulating 3-OHB was a strong predictor of all-cause mortality independently of NT-proBNP. Circulating FFAs were the best predictor of 3-OHB levels.
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Affiliation(s)
| | - Roni R Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev-Gentofte University Hospital, Herlev, Denmark
| | - Ida Gustafsson
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anders Jorsal
- Department of Internal Medicine, Regional Hospital Horsens, Horsens, Denmark
| | - Allan Flyvbjerg
- Steno Diabetes Center Copenhagen, The Capital Region of Denmark and University of Copenhagen, Copenhagen, Denmark
| | | | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Caroline Kistorp
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
| | - Mogens Johannsen
- Department of Forensic Medicine, Aarhus University, Aarhus, Denmark
| | - Niels Møller
- Department of Endocrinology and Metabolism, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Wiggers
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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3
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Oyetoro RO, Conners KM, Joo J, Turecamo S, Sampson M, Wolska A, Remaley AT, Otvos JD, Connelly MA, Larson NB, Bielinski SJ, Hashemian M, Shearer JJ, Roger VL. Circulating ketone bodies and mortality in heart failure: a community cohort study. Front Cardiovasc Med 2024; 11:1293901. [PMID: 38327494 PMCID: PMC10847221 DOI: 10.3389/fcvm.2024.1293901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/11/2024] [Indexed: 02/09/2024] Open
Abstract
Background The relationship between ketone bodies (KB) and mortality in patients with heart failure (HF) syndrome has not been well established. Objectives The aim of this study is to assess the distribution of KB in HF, identify clinical correlates, and examine the associations between plasma KB and all-cause mortality in a population-based HF cohort. Methods The plasma KB levels were measured by nuclear magnetic resonance spectroscopy. Multivariable linear regression was used to examine associations between clinical correlates and KB levels. Proportional hazard regression was employed to examine associations between KB (represented as both continuous and categorical variables) and mortality, with adjustment for several clinical covariates. Results Among the 1,382 HF patients with KB measurements, the median (IQR) age was 78 (68, 84) and 52% were men. The median (IQR) KB was found to be 180 (134, 308) μM. Higher KB levels were associated with advanced HF (NYHA class III-IV) and higher NT-proBNP levels (both P < 0.001). The median follow-up was 13.9 years, and the 5-year mortality rate was 51.8% [95% confidence interval (CI): 49.1%-54.4%]. The risk of death increased when KB levels were higher (HRhigh vs. low group 1.23; 95% CI: 1.05-1.44), independently of a validated clinical risk score. The association between higher KB and mortality differed by ejection fraction (EF) and was noticeably stronger among patients with preserved EF. Conclusions Most patients with HF exhibited KB levels that were consistent with those found in healthy adults. Elevated levels of KB were observed in patients with advanced HF. Higher KB levels were found to be associated with an increased risk of death, particularly in patients with preserved EF.
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Affiliation(s)
- Rebecca O. Oyetoro
- Heart Disease Phenomics Laboratory, Epidemiology and Community Health Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Katherine M. Conners
- Heart Disease Phenomics Laboratory, Epidemiology and Community Health Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Jungnam Joo
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Sarah Turecamo
- Heart Disease Phenomics Laboratory, Epidemiology and Community Health Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Maureen Sampson
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Anna Wolska
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Alan T. Remaley
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - James D. Otvos
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | | | - Nicholas B. Larson
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
| | - Suzette J. Bielinski
- Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
| | - Maryam Hashemian
- Heart Disease Phenomics Laboratory, Epidemiology and Community Health Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Joseph J. Shearer
- Heart Disease Phenomics Laboratory, Epidemiology and Community Health Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Véronique L. Roger
- Heart Disease Phenomics Laboratory, Epidemiology and Community Health Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
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4
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Marzoog B. Breathomics Detect the Cardiovascular Disease: Delusion or Dilution of the Metabolomic Signature. Curr Cardiol Rev 2024; 20:68-76. [PMID: 38318837 PMCID: PMC11327829 DOI: 10.2174/011573403x283768240124065853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 01/04/2024] [Accepted: 01/15/2024] [Indexed: 02/07/2024] Open
Abstract
Volatile organic compounds (VOCs) can be subdivided into exogenous and endogenous categories based on their origin. Analyzing the endogenous VOCs can provide insights into maintaining the internal organs' homeostasis. Despite the ongoing development and the current understanding, studies have suggested a link between cardiovascular metabolic alterations in patients with ischemic heart disease and elevated levels of ethane and isoprene detectable through exhaled breath analysis. Conversely, patients with chronic heart failure exhibit elevated acetone and pentane in their exhaled air. These substances originate from disturbances in the heart tissue, including cellular and subcellular modulations. Hypothetically, ethane levels in the exhaled breath analysis can demonstrate the severity of ischemic heart disease and, consequently, the risk of death in the next 10 years due to cardiovascular disease (CVD). Real-time direct mass spectrometry is the preferred method for assessing VOCs in exhaled breath analysis. The accuracy of this analysis depends on several factors, including the selection of the relevant breath fraction, the type of breath collection container (if used), and the pre-concentration technique.
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Affiliation(s)
- Basheer Marzoog
- World-Class Research Center, Digital Biodesign and Personalized Healthcare, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia
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5
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Tang WHW, Tranchito L, Albert C, Gul ZG, Cikach FS, Grove D, Wu Y, Dweik RA. Exhaled Breath Analysis Using Selected Ion Flow Tube Mass Spectrometry and Disease Severity in Heart Failure. Metabolites 2023; 13:1049. [PMID: 37887374 PMCID: PMC10608518 DOI: 10.3390/metabo13101049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/28/2023] Open
Abstract
Exhaled breath volatile organic compounds (VOCs) are elevated in heart failure (HF). The ability of VOCs to predict long term cardiovascular mortality and morbidity has not been independently verified. In 55 patients admitted with acute decompensated heart failure (ADHF), we measured exhaled breath acetone and pentane levels upon admission and after 48 h of diuresis. In a separate cohort of 51 cardiac patients undergoing cardiopulmonary exercise testing (CPET), we measured exhaled breath acetone and pentane levels before and at peak exercise. In the ADHF cohort, admission acetone levels correlated with lower left ventricular ejection fraction (LVEF, r = -0.297, p = 0.035). Greater weight loss with diuretic therapy correlated with a greater reduction in both acetone levels (r = -0.398, p = 0.003) and pentane levels (r = -0.309, p = 0.021). In patients with above-median weight loss (≥4.5 kg), patients demonstrated significantly greater percentage reduction in acetone (59% reduction vs. 7% increase, p < 0.001) and pentane (23% reduction vs. 2% reduction, p = 0.008). In the CPET cohort, admission acetone and pentane levels correlated with higher VE/VCO2 (r = 0.39, p = 0.005), (r = 0.035, p = 0.014). However, there were no significant correlations between baseline or peak exercise acetone and pentane levels and peak VO2. In longitudinal follow-up with a median duration of 33 months, patients with elevated exhaled acetone and pentane levels experienced higher composite adverse events of death, ventricular assist device implantation, or orthotopic heart transplantation. In patients admitted with ADHF, higher exhaled breath acetone levels are associated with lower LVEF and poorer outcomes, and greater reductions in exhaled breath acetone and pentane tracked with greater weight loss. Exhaled acetone and pentane may be novel biomarkers in heart failure worthy of future investigation.
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Affiliation(s)
- Wai Hong Wilson Tang
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Lily Tranchito
- Endocrinology & Metabolism Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Chonyang Albert
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Zeynep G. Gul
- Department of Surgery, Washington University School of Medicine at St Louis, St Louis, MO 63110, USA
| | - Frank S. Cikach
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - David Grove
- Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (D.G.); (R.A.D.)
- Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Yuping Wu
- Department of Mathematics, Cleveland State University, Cleveland, OH 44195, USA
| | - Raed A. Dweik
- Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (D.G.); (R.A.D.)
- Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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6
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Biagini D, Pugliese NR, Vivaldi FM, Ghimenti S, Lenzi A, De Angelis F, Ripszam M, Bruderer T, Armenia S, Cappeli F, Taddei S, Masi S, Francesco FD, Lomonaco T. Breath analysis combined with cardiopulmonary exercise testing and echocardiography for monitoring heart failure patients: the AEOLUS protocol. J Breath Res 2023; 17:046006. [PMID: 37524075 DOI: 10.1088/1752-7163/acec08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/31/2023] [Indexed: 08/02/2023]
Abstract
This paper describes the AEOLUS pilot study which combines breath analysis with cardiopulmonary exercise testing (CPET) and an echocardiographic examination for monitoring heart failure (HF) patients. Ten consecutive patients with a prior clinical diagnosis of HF with reduced left ventricular ejection fraction were prospectively enrolled together with 15 control patients with cardiovascular risk factors, including hypertension, type II diabetes or chronic ischemic heart disease. Breath samples were collected at rest and during CPET coupled with exercise stress echocardiography (CPET-ESE) protocol by means of needle trap micro-extraction and were analyzed through gas-chromatography coupled with mass spectrometry. The protocol also involved using of a selected ion flow tube mass spectrometer for a breath-by-breath isoprene and acetone analysis during exercise. At rest, HF patients showed increased breath levels of acetone and pentane, which are related to altered oxidation of fatty acids and oxidative stress, respectively. A significant positive correlation was observed between acetone and the gold standard biomarker NT-proBNP in plasma (r= 0.646,p< 0.001), both measured at rest. During exercise, some exhaled volatiles (e.g., isoprene) mirrored ventilatory and/or hemodynamic adaptation, whereas others (e.g., sulfide compounds and 3-hydroxy-2-butanone) depended on their origin. At peak effort, acetone levels in HF patients differed significantly from those of the control group, suggesting an altered myocardial and systemic metabolic adaptation to exercise for HF patients. These preliminary data suggest that concomitant acquisition of CPET-ESE and breath analysis is feasible and might provide additional clinical information on the metabolic maladaptation of HF patients to exercise. Such information may refine the identification of patients at higher risk of disease worsening.
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Affiliation(s)
- Denise Biagini
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Nicola R Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Federico M Vivaldi
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Silvia Ghimenti
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Alessio Lenzi
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Francesca De Angelis
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Matyas Ripszam
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Tobias Bruderer
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Silvia Armenia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Federica Cappeli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Fabio Di Francesco
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
| | - Tommaso Lomonaco
- Department of Chemistry and Industrial Chemistry, University of Pisa, Pisa, Italy
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7
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Abstract
The ketone bodies beta-hydroxybutyrate and acetoacetate are hepatically produced metabolites catabolized in extrahepatic organs. Ketone bodies are a critical cardiac fuel and have diverse roles in the regulation of cellular processes such as metabolism, inflammation, and cellular crosstalk in multiple organs that mediate disease. This review focuses on the role of cardiac ketone metabolism in health and disease with an emphasis on the therapeutic potential of ketosis as a treatment for heart failure (HF). Cardiac metabolic reprogramming, characterized by diminished mitochondrial oxidative metabolism, contributes to cardiac dysfunction and pathologic remodeling during the development of HF. Growing evidence supports an adaptive role for ketone metabolism in HF to promote normal cardiac function and attenuate disease progression. Enhanced cardiac ketone utilization during HF is mediated by increased availability due to systemic ketosis and a cardiac autonomous upregulation of ketolytic enzymes. Therapeutic strategies designed to restore high-capacity fuel metabolism in the heart show promise to address fuel metabolic deficits that underpin the progression of HF. However, the mechanisms involved in the beneficial effects of ketone bodies in HF have yet to be defined and represent important future lines of inquiry. In addition to use as an energy substrate for cardiac mitochondrial oxidation, ketone bodies modulate myocardial utilization of glucose and fatty acids, two vital energy substrates that regulate cardiac function and hypertrophy. The salutary effects of ketone bodies during HF may also include extra-cardiac roles in modulating immune responses, reducing fibrosis, and promoting angiogenesis and vasodilation. Additional pleotropic signaling properties of beta-hydroxybutyrate and AcAc are discussed including epigenetic regulation and protection against oxidative stress. Evidence for the benefit and feasibility of therapeutic ketosis is examined in preclinical and clinical studies. Finally, ongoing clinical trials are reviewed for perspective on translation of ketone therapeutics for the treatment of HF.
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Affiliation(s)
- Timothy R. Matsuura
- Cardiovascular Institute and Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Patrycja Puchalska
- Department of Medicine, Division of Molecular Medicine, University of Minnesota, Minneapolis, Minnesota 55455, USA
| | - Peter A. Crawford
- Department of Medicine, Division of Molecular Medicine, University of Minnesota, Minneapolis, Minnesota 55455, USA
- Department of Biochemistry, Molecular Biology, and Biophysics, University of Minnesota, Minneapolis, Minnesota 55455, USA
| | - Daniel P. Kelly
- Cardiovascular Institute and Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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8
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Ng ML, Ang X, Yap KY, Ng JJ, Goh ECH, Khoo BBJ, Richards AM, Drum CL. Novel Oxidative Stress Biomarkers with Risk Prognosis Values in Heart Failure. Biomedicines 2023; 11:biomedicines11030917. [PMID: 36979896 PMCID: PMC10046491 DOI: 10.3390/biomedicines11030917] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/17/2023] [Accepted: 02/26/2023] [Indexed: 03/18/2023] Open
Abstract
Oxidative stress (OS) is mediated by reactive oxygen species (ROS), which in cardiovascular and other disease states, damage DNA, lipids, proteins, other cellular and extra-cellular components. OS is both initiated by, and triggers inflammation, cardiomyocyte apoptosis, matrix remodeling, myocardial fibrosis, and neurohumoral activation. These have been linked to the development of heart failure (HF). Circulating biomarkers generated by OS offer potential utility in patient management and therapeutic targeting. Novel OS-related biomarkers such as NADPH oxidases (sNox2-dp, Nrf2), advanced glycation end-products (AGE), and myeloperoxidase (MPO), are signaling molecules reflecting pathobiological changes in HF. This review aims to evaluate current OS-related biomarkers and their associations with clinical outcomes and to highlight those with greatest promise in diagnosis, risk stratification and therapeutic targeting in HF.
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Affiliation(s)
- Mei Li Ng
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Xu Ang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Kwan Yi Yap
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Jun Jie Ng
- Vascular Surgery, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore 119074, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Eugene Chen Howe Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Benjamin Bing Jie Khoo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Arthur Mark Richards
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Cardiovascular Research Institute, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, NUHCS, Singapore 119228, Singapore
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117599, Singapore
| | - Chester Lee Drum
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Cardiovascular Research Institute, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, NUHCS, Singapore 119228, Singapore
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117599, Singapore
- Correspondence:
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9
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Ketone Bodies and Cardiovascular Disease: An Alternate Fuel Source to the Rescue. Int J Mol Sci 2023; 24:ijms24043534. [PMID: 36834946 PMCID: PMC9962558 DOI: 10.3390/ijms24043534] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/04/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023] Open
Abstract
The increased metabolic activity of the heart as a pump involves a high demand of mitochondrial adenosine triphosphate (ATP) production for its mechanical and electrical activities accomplished mainly via oxidative phosphorylation, supplying up to 95% of the necessary ATP production, with the rest attained by substrate-level phosphorylation in glycolysis. In the normal human heart, fatty acids provide the principal fuel (40-70%) for ATP generation, followed mainly by glucose (20-30%), and to a lesser degree (<5%) by other substrates (lactate, ketones, pyruvate and amino acids). Although ketones contribute 4-15% under normal situations, the rate of glucose use is drastically diminished in the hypertrophied and failing heart which switches to ketone bodies as an alternate fuel which are oxidized in lieu of glucose, and if adequately abundant, they reduce myocardial fat delivery and usage. Increasing cardiac ketone body oxidation appears beneficial in the context of heart failure (HF) and other pathological cardiovascular (CV) conditions. Also, an enhanced expression of genes crucial for ketone break down facilitates fat or ketone usage which averts or slows down HF, potentially by avoiding the use of glucose-derived carbon needed for anabolic processes. These issues of ketone body utilization in HF and other CV diseases are herein reviewed and pictorially illustrated.
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10
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Manla Y, Kuan W, Clark AL, Cleland JGF, Pellicori P. Ketone Bodies in Acute Heart Failure: Fuel for Thought. J Card Fail 2023; 29:42-44. [PMID: 36402423 DOI: 10.1016/j.cardfail.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/03/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Yosef Manla
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - William Kuan
- Department of Pharmacy Services, University of Kentucky Albert B. Chandler Hospital, Lexington, KY, USA
| | - Andrew L Clark
- Department of Cardiology, Hull University Hospitals Trust, Castle Hill Hospital, Yorkshire, England
| | - John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland.
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11
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Gouzi F, Ayache D, Hédon C, Molinari N, Vicet A. Breath acetone concentration: too heterogeneous to constitute a diagnosis or prognosis biomarker in heart failure? A systematic review and meta-analysis. J Breath Res 2021; 16. [PMID: 34727537 DOI: 10.1088/1752-7163/ac356d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 11/02/2021] [Indexed: 12/19/2022]
Abstract
Introduction. Exhaled breath acetone (ExA) has been investigated as a biomarker for heart failure (HF). Yet, barriers to its use in the clinical field have not been identified. The aim of this systematic review and meta-analysis was to assess the ExA heterogeneity and factors of variability in healthy controls (HC), to identify its relations with HF diagnosis and prognostic factors and to assess its diagnosis and prognosis accuracy in HF patients.Methods. A systematic search was conducted in PUBMED and Web of Science database. All studies with HC and HF patients with a measured ExA were included and studies providing ExA's diagnosis and prognosis accuracy were identified.Results. Out of 971 identified studies, 18 studies involving 833 HC and 1009 HF patients were included in the meta-analysis. In HC, ExA showed an important heterogeneity (I2= 99%). Variability factors were fasting state, sampling type and analytical method. The mean ExA was 1.89 times higher in HF patients vs. HC (782 [531-1032] vs. 413 [347-478] ppbv;p< 0.001). One study showed excellent diagnosis accuracy, and one showed a good prognosis value. ExA correlated with New York Heart Association (NYHA) dyspnea (p< 0.001) and plasma brain natriuretic peptide (p< 0.001). Studies showed a poor definition and reporting of included subjects.Discussion. Despite the between-study heterogeneity in HC, the evidence of an excellent diagnosis and prognosis value of ExA in HF from single studies can be extended to clinical populations worldwide. Factors of variability (ExA procedure and breath sampling) could further improve the diagnosis and prognosis values of this biomarker in HF patients.
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Affiliation(s)
- Fares Gouzi
- PhyMedExp, University of Montpellier, INSERM, CNRS, CHRU, Montpellier, France
| | - Diba Ayache
- IES, Montpellier University, CNRS, F-34000 Montpellier, France
| | - Christophe Hédon
- PhyMedExp, University of Montpellier, INSERM, CNRS, CHRU, Montpellier, France
| | - Nicolas Molinari
- IDESP, INSERM, Montpellier University, Montpellier University Hospital, Montpellier, France
| | - Aurore Vicet
- IES, Montpellier University, CNRS, F-34000 Montpellier, France
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12
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Marcondes-Braga FG, Gioli-Pereira L, Bernardez-Pereira S, Batista GL, Mangini S, Issa VS, Fernandes F, Bocchi EA, Ayub-Ferreira SM, Mansur AJ, Gutz IGR, Krieger JE, Pereira AC, Bacal F. Exhaled breath acetone for predicting cardiac and overall mortality in chronic heart failure patients. ESC Heart Fail 2020; 7:1744-1752. [PMID: 32383349 PMCID: PMC7373929 DOI: 10.1002/ehf2.12736] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/27/2020] [Accepted: 04/15/2020] [Indexed: 11/11/2022] Open
Abstract
Aims Exhaled breath acetone (EBA) has been described as a new biomarker of heart failure (HF) diagnosis. EBA concentration increases according to severity of HF and is associated with poor prognosis, especially in acute decompensated HF. However, there are no data on chronic HF patients. The aim is to evaluate the role of EBA for predicting cardiac and overall mortality in chronic HF patients. Methods and results In GENIUS‐HF cohort, chronic patients were enrolled between August 2012 and December 2014. All patients had left ventricular ejection fraction ≤ 50%, and the diagnosis was established according to Framingham criteria. After consent, patients were submitted to clinical evaluation and exhaled breath collection. EBA identification and quantitative determination were done by spectrophotometry. The clinical characteristics associated with acetone were identified. All participants were followed for 18 months to assess cardiac and overall mortality. Around 700 participants were enrolled in the current analysis. Patients were 55.4 ± 12.2 years old, 67.6% male patients, and 81% New York Heart Association I/II with left ventricular ejection fraction of 32 ± 8.6%. EBA median concentration was 0.6 (0.3–1.2) ug/L. Acetone levels increased with the number of symptoms of HF and were associated with right HF signs/symptoms and liver biochemical changes. EBA at highest quartile (EBA > 1.2ug/L) was associated with a significantly worse prognosis (log rank test, P < 0.001). Cox proportional multivariable regression model revealed that EBA > 1.20ug/L was an independent predictor of cardiac (P = 0.011) and overall (P = 0.010) mortality in our population. Conclusions This study shows that EBA levels reflect clinical HF features, especially right HF signs/symptoms. EBA is an independent predictor of cardiac and overall mortality in chronic HF patients.
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Affiliation(s)
- Fabiana G Marcondes-Braga
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Dr Eneas de Carvalho Aguiar, 44-Cerqueira Cesar, São Paulo, 0540300, Brazil
| | - Luciana Gioli-Pereira
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Dr Eneas de Carvalho Aguiar, 44-Cerqueira Cesar, São Paulo, 0540300, Brazil
| | - Sabrina Bernardez-Pereira
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Dr Eneas de Carvalho Aguiar, 44-Cerqueira Cesar, São Paulo, 0540300, Brazil
| | | | - Sandrigo Mangini
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Dr Eneas de Carvalho Aguiar, 44-Cerqueira Cesar, São Paulo, 0540300, Brazil
| | - Victor S Issa
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Dr Eneas de Carvalho Aguiar, 44-Cerqueira Cesar, São Paulo, 0540300, Brazil
| | - Fabio Fernandes
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Dr Eneas de Carvalho Aguiar, 44-Cerqueira Cesar, São Paulo, 0540300, Brazil
| | - Edimar A Bocchi
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Dr Eneas de Carvalho Aguiar, 44-Cerqueira Cesar, São Paulo, 0540300, Brazil
| | - Silvia M Ayub-Ferreira
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Dr Eneas de Carvalho Aguiar, 44-Cerqueira Cesar, São Paulo, 0540300, Brazil
| | - Alfredo J Mansur
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Dr Eneas de Carvalho Aguiar, 44-Cerqueira Cesar, São Paulo, 0540300, Brazil
| | - Ivano G R Gutz
- Institute of Chemistry (IQ-USP), University of Sao Paulo, Sao Paulo, Brazil
| | - Jose E Krieger
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Dr Eneas de Carvalho Aguiar, 44-Cerqueira Cesar, São Paulo, 0540300, Brazil
| | - Alexandre C Pereira
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Dr Eneas de Carvalho Aguiar, 44-Cerqueira Cesar, São Paulo, 0540300, Brazil
| | - Fernando Bacal
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Dr Eneas de Carvalho Aguiar, 44-Cerqueira Cesar, São Paulo, 0540300, Brazil
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