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Tkaczyszyn M, Fudim M, Ponikowski P, Biegus J. Pathophysiology and Treatment Opportunities of Iron Deficiency in Heart Failure: Is There a Need for Further Trials? Curr Heart Fail Rep 2023; 20:300-307. [PMID: 37428429 PMCID: PMC10421819 DOI: 10.1007/s11897-023-00611-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/11/2023]
Abstract
PURPOSE OF REVIEW Iron deficiency (ID) complicates heart failure (HF) at different stages of the natural history of the disease; however, this frequent comorbidity is still not comprehensively understood and investigated in terms of pathophysiology. Intravenous iron therapy with ferric carboxymaltose (FCM) should be considered to improve the quality of life, exercise capacity, and symptoms in stable HF with ID, as well as to reduce HF hospitalizations in iron-deficient patients stabilized after an episode of acute HF. The therapy with intravenous iron, however, continues to generate important clinical questions for cardiologists. RECENT FINDINGS In the current paper, we discuss the class effect concept for intravenous iron formulations beyond FCM, based on the experiences of nephrologists who administer different intravenous iron formulations in advanced chronic kidney disease complicated with ID and anemia. Furthermore, we discuss the neutral effects of oral iron therapy in patients with HF, because there are still some reasons to further explore this route of supplementation. The different definitions of ID applied in HF studies and new doubts regarding possible interactions of intravenous iron with sodium-glucose co-transporter type 2 inhibitors are also emphasized. The experiences of other medical specializations may provide new information on how to optimally replenish iron in patients with HF and ID.
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Affiliation(s)
- Michał Tkaczyszyn
- Institute of Heart Diseases, Wroclaw Medical University, Borowska 213, 50-556, Wroclaw, Poland.
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland.
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Borowska 213, 50-556, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Borowska 213, 50-556, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
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2
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Savarese G, von Haehling S, Butler J, Cleland JGF, Ponikowski P, Anker SD. Iron deficiency and cardiovascular disease. Eur Heart J 2023; 44:14-27. [PMID: 36282723 PMCID: PMC9805408 DOI: 10.1093/eurheartj/ehac569] [Citation(s) in RCA: 74] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/11/2022] [Accepted: 09/27/2022] [Indexed: 02/07/2023] Open
Abstract
Iron deficiency (ID) is common in patients with cardiovascular disease. Up to 60% of patients with coronary artery disease, and an even higher proportion of those with heart failure (HF) or pulmonary hypertension have ID; the evidence for cerebrovascular disease, aortic stenosis and atrial fibrillation is less robust. The prevalence of ID increases with the severity of cardiac and renal dysfunction and is probably more common amongst women. Insufficient dietary iron, reduced iron absorption due to increases in hepcidin secondary to the low-grade inflammation associated with atherosclerosis and congestion or reduced gastric acidity, and increased blood loss due to anti-thrombotic therapy or gastro-intestinal or renal disease may all cause ID. For older people in the general population and patients with HF with reduced ejection fraction (HFrEF), both anaemia and ID are associated with a poor prognosis; each may confer independent risk. There is growing evidence that ID is an important therapeutic target for patients with HFrEF, even if they do not have anaemia. Whether this is also true for other HF phenotypes or patients with cardiovascular disease in general is currently unknown. Randomized trials showed that intravenous ferric carboxymaltose improved symptoms, health-related quality of life and exercise capacity and reduced hospitalizations for worsening HF in patients with HFrEF and mildly reduced ejection fraction (<50%). Since ID is easy to treat and is effective for patients with HFrEF, such patients should be investigated for possible ID. This recommendation may extend to other populations in the light of evidence from future trials.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas TX, USA
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health & Wellebing, University of Glasgow, Glasgow, UK
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
- Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Centre for Regenerative Therapies, German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
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3
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Kalra PR, Cleland JGF, Petrie MC, Thomson EA, Kalra PA, Squire IB, Ahmed FZ, Al-Mohammad A, Cowburn PJ, Foley PWX, Graham FJ, Japp AG, Lane RE, Lang NN, Ludman AJ, Macdougall IC, Pellicori P, Ray R, Robertson M, Seed A, Ford I. Intravenous ferric derisomaltose in patients with heart failure and iron deficiency in the UK (IRONMAN): an investigator-initiated, prospective, randomised, open-label, blinded-endpoint trial. Lancet 2022; 400:2199-2209. [PMID: 36347265 DOI: 10.1016/s0140-6736(22)02083-9] [Citation(s) in RCA: 112] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND For patients with heart failure, reduced left ventricular ejection fraction and iron deficiency, intravenous ferric carboxymaltose administration improves quality of life and exercise capacity in the short-term and reduces hospital admissions for heart failure up to 1 year. We aimed to evaluate the longer-term effects of intravenous ferric derisomaltose on cardiovascular events in patients with heart failure. METHODS IRONMAN was a prospective, randomised, open-label, blinded-endpoint trial done at 70 hospitals in the UK. Patients aged 18 years or older with heart failure (left ventricular ejection fraction ≤45%) and transferrin saturation less than 20% or serum ferritin less than 100 μg/L were eligible. Participants were randomly assigned (1:1) using a web-based system to intravenous ferric derisomaltose or usual care, stratified by recruitment context and trial site. The trial was open label, with masked adjudication of the outcomes. Intravenous ferric derisomaltose dose was determined by patient bodyweight and haemoglobin concentration. The primary outcome was recurrent hospital admissions for heart failure and cardiovascular death, assessed in all validly randomly assigned patients. Safety was assessed in all patients assigned to ferric derisomaltose who received at least one infusion and all patients assigned to usual care. A COVID-19 sensitivity analysis censoring follow-up on Sept 30, 2020, was prespecified. IRONMAN is registered with ClinicalTrials.gov, NCT02642562. FINDINGS Between Aug 25, 2016, and Oct 15, 2021, 1869 patients were screened for eligibility, of whom 1137 were randomly assigned to receive intravenous ferric derisomaltose (n=569) or usual care (n=568). Median follow-up was 2·7 years (IQR 1·8-3·6). 336 primary endpoints (22·4 per 100 patient-years) occurred in the ferric derisomaltose group and 411 (27·5 per 100 patient-years) occurred in the usual care group (rate ratio [RR] 0·82 [95% CI 0·66 to 1·02]; p=0·070). In the COVID-19 analysis, 210 primary endpoints (22·3 per 100 patient-years) occurred in the ferric derisomaltose group compared with 280 (29·3 per 100 patient-years) in the usual care group (RR 0·76 [95% CI 0·58 to 1·00]; p=0·047). No between-group differences in deaths or hospitalisations due to infections were observed. Fewer patients in the ferric derisomaltose group had cardiac serious adverse events (200 [36%]) than in the usual care group (243 [43%]; difference -7·00% [95% CI -12·69 to -1·32]; p=0·016). INTERPRETATION For a broad range of patients with heart failure, reduced left ventricular ejection fraction and iron deficiency, intravenous ferric derisomaltose administration was associated with a lower risk of hospital admissions for heart failure and cardiovascular death, further supporting the benefit of iron repletion in this population. FUNDING British Heart Foundation and Pharmacosmos.
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Affiliation(s)
- Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK; College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK; Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | | | - Philip A Kalra
- Department of Renal Medicine, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK; Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Iain B Squire
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Fozia Z Ahmed
- Department of Cardiology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Abdallah Al-Mohammad
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Peter J Cowburn
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Paul W X Foley
- Wiltshire Cardiac Centre, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Fraser J Graham
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Alan G Japp
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Rebecca E Lane
- Department of Cardiology, Royal Brompton and Harefield Hospitals, London, UK
| | - Ninian N Lang
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Andrew J Ludman
- Department of Cardiology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | | | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Robin Ray
- Cardiology Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Michele Robertson
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Alison Seed
- Department of Cardiology, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK.
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Arora EK, Sharma V. Iron metabolism: pathways and proteins in homeostasis. REV INORG CHEM 2022. [DOI: 10.1515/revic-2022-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Iron is essential to human survival. The biological role and trafficking of this trace essential inorganic element which is also a potential toxin is constantly being researched and unfolded. Vital for oxygen transport, DNA synthesis, electron transport, neurotransmitter biosynthesis and present in numerous other heme and non-heme enzymes the physiological roles are immense. Understanding the molecules and pathways that regulate this essential element at systemic and cellular levels are of importance in improving therapeutic strategies for iron related disorders. This review highlights the progress in understanding the metabolism and trafficking of iron along with the pathophysiology of iron related disorders.
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Affiliation(s)
- Ekta Kundra Arora
- Chemistry Department, St. Stephen’s College , University of Delhi , Delhi 110007 , India
| | - Vibha Sharma
- Chemistry Department, St. Stephen’s College , University of Delhi , Delhi 110007 , India
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5
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Del Canto I, Santas E, Cardells I, Miñana G, Palau P, Llàcer P, Fácila L, López-Vilella R, Almenar L, Bodí V, López-Lereu MP, Monmeneu JV, Sanchis J, Moratal D, Maceira AM, de la Espriella R, Chorro FJ, Bayés-Genís A, Núñez J. Short-Term Changes in Left and Right Ventricular Cardiac Magnetic Resonance Feature Tracking Strain Following Ferric Carboxymaltose in Patients With Heart Failure: A Substudy of the Myocardial-IRON Trial. J Am Heart Assoc 2022; 11:e022214. [PMID: 35301854 PMCID: PMC9075490 DOI: 10.1161/jaha.121.022214] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The mechanisms explaining the clinical benefits of ferric carboximaltose (FCM) in patients with heart failure, reduced or intermediate left ventricular ejection fraction, and iron deficiency remain not fully clarified. The Myocardial‐IRON trial showed short‐term cardiac magnetic resonance (CMR) changes suggesting myocardial iron repletion following administration of FCM but failed to find a significant increase in left ventricular ejection fraction in the whole sample. Conversely, the strain assessment could evaluate more specifically subtle changes in contractility. In this subanalysis, we aimed to evaluate the effect of FCM on the short‐term left and right ventricular CMR feature tracking derived strain. Methods and Results This is a post hoc subanalysis of the double‐blind, placebo‐controlled, randomized clinical trial that enrolled 53 ambulatory patients with heart failure and left ventricular ejection fraction <50%, and iron deficiency [Myocardial‐IRON trial (NCT03398681)]. Three‐dimensional left and 2‐dimensional right ventricular CMR tracking strain (longitudinal, circumferential, and radial) changes were evaluated before, 7 and 30 days after randomization using linear mixed‐effect analysis. The median (interquartile range) age of the sample was 73 years (65–78), and 40 (75.5%) were men. At baseline, there were no significant differences in CMR feature tracking strain parameters across both treatment arms. At 7 days, the only global 3‐dimensional left ventricular circumferential strain was significantly higher in the FCM treatment‐arm (difference: −1.6%, P=0.001). At 30 days, and compared with placebo, global 3‐dimensional left ventricular strain parameters significantly improved in those allocated to FCM treatment‐arm [longitudinal (difference: −2.3%, P<0.001), circumferential (difference: −2.5%, P<0.001), and radial (difference: 4.2%, P=0.002)]. Likewise, significant improvements in global right ventricular strain parameters were found in the active arm at 30 days (longitudinal [difference: −3.3%, P=0.010], circumferential [difference: −4.5%, P<0.001], and radial [difference: 4.5%, P=0.027]). Conclusions In patients with stable heart failure, left ventricular ejection fraction <50%, and iron deficiency, treatment with FCM was associated with short‐term improvements in left and right ventricular function assessed by CMR feature tracking derived strain parameters. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03398681.
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Affiliation(s)
- Irene Del Canto
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain.,Center for Biomaterials and Tissue Engineering Universitat Politècnica de València Valencia Spain
| | - Enrique Santas
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
| | | | - Gema Miñana
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
| | - Patricia Palau
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
| | - Pau Llàcer
- Internal Medicine Department Hospital de Manises Manises Spain
| | - Lorenzo Fácila
- Cardiology Department Hospital General Universitario de Valencia Valencia Spain
| | | | - Luis Almenar
- Cardiology Department Hospital Universitario La Fe de Valencia Valencia Spain
| | - Vicent Bodí
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
| | | | - Jose V Monmeneu
- Cardiovascular Imaging Unit Ascires Biomedical GroupValencia Spain
| | - Juan Sanchis
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
| | - David Moratal
- Center for Biomaterials and Tissue Engineering Universitat Politècnica de València Valencia Spain
| | - Alicia M Maceira
- Cardiovascular Imaging Unit Ascires Biomedical GroupValencia Spain
| | - Rafael de la Espriella
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
| | - Francisco J Chorro
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
| | - Antoni Bayés-Genís
- CIBER Cardiovascular Madrid Spain.,Cardiology Department and Heart Failure Unit Hospital Universitari Germans Trias i Pujol Badalona Spain.,Universitat Autonoma de Barcelona Barcelona Spain
| | - Julio Núñez
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
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Monocyte Subsets in Patients with Chronic Heart Failure Treated with Cardiac Resynchronization Therapy. Cells 2021; 10:cells10123482. [PMID: 34943990 PMCID: PMC8700101 DOI: 10.3390/cells10123482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/24/2021] [Accepted: 12/06/2021] [Indexed: 02/06/2023] Open
Abstract
Background: The exact role of individual inflammatory factor in heart failure with reduced ejection fraction (HFrEF) remains elusive. The study aimed to evaluate three monocyte subsets (classical-CD14++CD16−, intermediate-CD14++CD16+, and nonclassical-CD14+CD16++) in HFrEF patients and to assess the effect of the cardiac resynchronization therapy (CRT) on the changes in monocyte compartment. Methods: The study included 85 patients with stable HFrEF. Twenty-five of them underwent CRT device implantation with subsequent 6-month assessment. The control group consisted of 23 volunteers without HFrEF. Results: The analysis revealed that frequencies of non-classical-CD14+CD16++ monocytes were lower in HFrEF patients compared to the control group (6.98 IQR: 4.95–8.65 vs. 8.37 IQR: 6.47–9.94; p = 0.021), while CD14++CD16+ and CD14++CD16− did not differ. The analysis effect of CRT on the frequency of analysed monocyte subsets 6 months after CRT device implantation showed a significant increase in CD14+CD16++ (from 7 IQR: 4.5–8.4 to 7.9 IQR: 6.5–9.5; p = 0.042) and CD14++CD16+ (from 5.1 IQR: 3.7–6.5 to 6.8 IQR: 5.4–7.4; p = 0.017) monocytes, while the frequency of steady-state CD14++CD16− monocytes was decreased (from 81.4 IQR: 78–86.2 to 78.2 IQR: 76.1–81.7; p = 0.003). Conclusions: HFrEF patients present altered monocyte composition. CRT-related changes in the monocyte compartment achieve levels observed in controls without HFrEF.
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7
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Koleini N, Shapiro JS, Geier J, Ardehali H. Ironing out mechanisms of iron homeostasis and disorders of iron deficiency. J Clin Invest 2021; 131:e148671. [PMID: 34060484 DOI: 10.1172/jci148671] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Iron plays an important role in mammalian physiological processes. It is a critical component for the function of many proteins, including enzymes that require heme and iron-sulfur clusters. However, excess iron is also detrimental because of its ability to catalyze the formation of reactive oxygen species. As a result, cellular and systemic iron levels are tightly regulated to prevent oxidative damage. Iron deficiency can lead to a number of pathological conditions, the most prominent being anemia. Iron deficiency should be corrected to improve adult patients' symptoms and to facilitate normal growth during fetal development and childhood. However, inappropriate use of intravenous iron in chronic conditions, such as cancer and heart failure, in the absence of clear iron deficiency can lead to unwanted side effects. Thus, this form of therapy should be reserved for certain patients who cannot tolerate oral iron and need rapid iron replenishment. Here, we will review cellular and systemic iron homeostasis and will discuss complications of iron deficiency.
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8
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Understanding the common mechanisms of heart and skeletal muscle wasting in cancer cachexia. Oncogenesis 2021; 10:1. [PMID: 33419963 PMCID: PMC7794402 DOI: 10.1038/s41389-020-00288-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/26/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022] Open
Abstract
Cachexia is a severe complication of cancer that adversely affects the course of the disease, with currently no effective treatments. It is characterized by a progressive atrophy of skeletal muscle and adipose tissue, resulting in weight loss, a reduced quality of life, and a shortened life expectancy. Although the cachectic condition primarily affects the skeletal muscle, a tissue that accounts for ~40% of total body weight, cachexia is considered a multi-organ disease that involves different tissues and organs, among which the cardiac muscle stands out for its relevance. Patients with cancer often experience severe cardiac abnormalities and manifest symptoms that are indicative of chronic heart failure, including fatigue, shortness of breath, and impaired exercise tolerance. Furthermore, cardiovascular complications are among the major causes of death in cancer patients who experienced cachexia. The lack of effective treatments for cancer cachexia underscores the need to improve our understanding of the underlying mechanisms. Increasing evidence links the wasting of the cardiac and skeletal muscles to metabolic alterations, primarily increased energy expenditure, and to increased proteolysis, ensuing from activation of the major proteolytic machineries of the cell, including ubiquitin-dependent proteolysis and autophagy. This review aims at providing an overview of the key mechanisms of cancer cachexia, with a major focus on those that are shared by the skeletal and cardiac muscles.
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9
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Sierpinski R, Josiak K, Suchocki T, Wojtas-Polc K, Mazur G, Butrym A, Rozentryt P, van der Meer P, Comin-Colet J, von Haehling S, Kosmala W, Przewlocka-Kosmala M, Banasiak W, Nowak J, Voors AA, Anker SD, Cleland JGF, Ponikowski P, Jankowska EA. High soluble transferrin receptor in patients with heart failure: a measure of iron deficiency and a strong predictor of mortality. Eur J Heart Fail 2020; 23:919-932. [PMID: 33111457 DOI: 10.1002/ejhf.2036] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/13/2020] [Accepted: 10/24/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS Iron deficiency (ID) is frequent in heart failure (HF), linked with exercise intolerance and poor prognosis. Intravenous iron repletion improves clinical status in HF patients with left ventricular ejection fraction (LVEF) ≤45%. However, uncertainty exists about the accuracy of serum biomarkers in diagnosing ID. The aims of this study were (i) to identify the iron biomarker with the greatest accuracy for the diagnosis of ID in bone marrow in patients with ischaemic HF, and (ii) to establish the prevalence of ID using this biomarker and its prognostic value in HF patients. METHODS AND RESULTS Bone marrow was stained for iron in 30 patients with ischaemic HF with LVEF ≤45% and 10 healthy controls, and ID was diagnosed for 0-1 grades (Gale scale). A total of 791 patients with HF with LVEF ≤45% were prospectively followed up for 3 years. Serum ferritin, transferrin saturation, soluble transferrin receptor (sTfR) were assessed as iron biomarkers. Most patients with HF (n = 25, 83%) had ID in bone marrow, but none of the controls (P < 0.001). Serum sTfR had the best accuracy in predicting ID in bone marrow (area under the curve 0.920, 95% confidence interval 0.761-0.987, for cut-off 1.25 mg/L sensitivity 84%, specificity 100%). Serum sTfR was ≥1.25 mg/L in 47% of HF patients, in 56% and 46% of anaemics and non-anaemics, respectively (P < 0.05). The reclassification methods revealed that serum sTfR significantly added the prognostic value to the baseline prognostic model, and to the greater extent than plasma N-terminal pro B-type natriuretic peptide. Based on internal derivation and validation procedures, serum sTfR ≥1.41 mg/L was the optimal threshold for predicting 3-year mortality, independent of other established variables. CONCLUSIONS High serum sTfR accurately reflects depleted iron stores in bone marrow in patients with HF, and identifies those with a high 3-year mortality.
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Affiliation(s)
- Radoslaw Sierpinski
- Medical Research Agency, Warsaw, Poland.,Collegium Medicum, Cardinal Wyszyński University in Warsaw, Warsaw, Poland
| | - Krystian Josiak
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Tomasz Suchocki
- Biostatistics Group, Department of Genetics, Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
| | - Katarzyna Wojtas-Polc
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Department of Cardiology, Military Hospital, Wroclaw, Poland
| | - Grzegorz Mazur
- Department of Internal Diseases, Occupational Medicine and Hypertension, Wroclaw Medical University, Wroclaw, Poland
| | - Aleksandra Butrym
- Department of Internal Diseases, Occupational Medicine and Hypertension, Wroclaw Medical University, Wroclaw, Poland
| | - Piotr Rozentryt
- Third Department of Cardiology, Silesian Center for Heart Disease, Zabrze, Poland
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Josep Comin-Colet
- Department of Cardiology, Heart Failure Program, Hospital del Mar, Barcelona, Spain.,Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Stephan von Haehling
- Division of Applied Cachexia Research, Department of Cardiology, Charité Medical School, Berlin, Germany
| | - Wojciech Kosmala
- Centre for Heart Diseases, University Hospital, Wroclaw, Poland.,Department of Cardiology, Wroclaw Medical University, Wroclaw, Poland
| | - Monika Przewlocka-Kosmala
- Centre for Heart Diseases, University Hospital, Wroclaw, Poland.,Department of Cardiology, Wroclaw Medical University, Wroclaw, Poland
| | | | - Jolanta Nowak
- Third Department of Cardiology, Silesian Center for Heart Disease, Zabrze, Poland
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Stefan D Anker
- Division of Applied Cachexia Research, Department of Cardiology, Charité Medical School, Berlin, Germany
| | - John G F Cleland
- Department of Cardiology, Hull York Medical School, University of Hull, Castle Hill Hospital, Kingston-upon-Hull, UK
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Ewa A Jankowska
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Centre for Heart Diseases, University Hospital, Wroclaw, Poland
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10
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Santas E, Miñana G, Cardells I, Palau P, Llàcer P, Fácila L, Almenar L, López‐Lereu MP, Monmeneu JV, Sanchis J, Maceira AM, Bayés‐Genís A, Núñez J. Short-term changes in left and right systolic function following ferric carboxymaltose: a substudy of the Myocardial-IRON trial. ESC Heart Fail 2020; 7:4222-4230. [PMID: 33040491 PMCID: PMC7754736 DOI: 10.1002/ehf2.13053] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/22/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022] Open
Abstract
AIMS The mechanisms underlying the beneficial effect of ferric carboxymaltose (FCM) in patients with heart failure (HF) and iron deficiency (ID) have not been completely characterized. The Myocardial-IRON trial was a double-blind, randomized trial that evaluated myocardial iron repletion following FCM vs. placebo in 53 patients with HF and ID. In this post hoc analysis, we evaluated whether treatment with FCM was associated with cardiac magnetic resonance changes in left and right ventricular function (LVEF and RVEF, respectively) at different points of systolic dysfunction. METHODS AND RESULTS We included patients from the Myocardial-IRON trial with left and right ventricular systolic dysfunction (LVSD and RVSD, respectively) at enrolment. Linear mixed regression models were used to evaluate changes at 7 and 30 days on LVEF and RVEF at cardiac magnetic resonance. At enrolment, 27 (50.9%) and 38 (71.7%) patients had LVEF < 40% (LVSD1 ) or <45% (LVSD2 ), respectively, and 10 (18.9%) and 17 (32.1%) patients had RVEF < 45% (RVSD1 ) or <51% in women and <52% in men (RVSD2) , respectively. Treatment with FCM was associated with a significant improvement in LVEF at 30 days (LVSD1 : Δ2.3%, P < 0.001; LVSD2 : Δ4.1, P = 0.014). FCM was also associated with a significant and early improvement in RVEF at 7 days (RVSD1 : Δ6.9%, P = 0.003; RVSD2 : Δ3.2%, P = 0.003) that persisted at 30 days (RVSD1 : Δ8.1%, P < 0.001; RVSD2 : Δ4.7%, P < 0.001). CONCLUSIONS In patients with HF and systolic dysfunction with ID, FCM was associated with short-term improvement in LVEF and, especially, in RVEF.
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Affiliation(s)
- Enrique Santas
- Cardiology DepartmentHospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVAValenciaSpain
- CIBER CardiovascularMadridSpain
| | - Gema Miñana
- Cardiology DepartmentHospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVAValenciaSpain
- CIBER CardiovascularMadridSpain
| | | | - Patricia Palau
- Cardiology DepartmentHospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVAValenciaSpain
- CIBER CardiovascularMadridSpain
| | - Pau Llàcer
- Internal Medicine DepartmentHospital Universitario Ramón y CajalMadridSpain
| | - Lorenzo Fácila
- Cardiology DepartmentHospital General Universitario de ValenciaValenciaSpain
| | - Luis Almenar
- Cardiology DepartmentHospital Universitario La Fe de ValenciaValenciaSpain
| | | | - Jose V. Monmeneu
- Cardiovascular Imaging UnitERESA‐Ascires Biomedical GroupValenciaSpain
| | - Juan Sanchis
- Cardiology DepartmentHospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVAValenciaSpain
- CIBER CardiovascularMadridSpain
| | - Alicia M. Maceira
- Cardiovascular Imaging UnitERESA‐Ascires Biomedical GroupValenciaSpain
| | - Antoni Bayés‐Genís
- CIBER CardiovascularMadridSpain
- Cardiology Department and Heart Failure UnitHospital Universitari Germans Trias i Pujol, Universitat Autonoma de BarcelonaBarcelonaSpain
| | - Julio Núñez
- Cardiology DepartmentHospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVAValenciaSpain
- CIBER CardiovascularMadridSpain
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Fang X, Cai Z, Wang H, Han D, Cheng Q, Zhang P, Gao F, Yu Y, Song Z, Wu Q, An P, Huang S, Pan J, Chen HZ, Chen J, Linkermann A, Min J, Wang F. Loss of Cardiac Ferritin H Facilitates Cardiomyopathy via Slc7a11-Mediated Ferroptosis. Circ Res 2020; 127:486-501. [PMID: 32349646 DOI: 10.1161/circresaha.120.316509] [Citation(s) in RCA: 411] [Impact Index Per Article: 102.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
RATIONALE Maintaining iron homeostasis is essential for proper cardiac function. Both iron deficiency and iron overload are associated with cardiomyopathy and heart failure via complex mechanisms. Although ferritin plays a central role in iron metabolism by storing excess cellular iron, the molecular function of ferritin in cardiomyocytes remains unknown. OBJECTIVE To characterize the functional role of Fth (ferritin H) in mediating cardiac iron homeostasis and heart disease. METHODS AND RESULTS Mice expressing a conditional Fth knockout allele were crossed with 2 distinct Cre recombinase-expressing mouse lines, resulting in offspring that lack Fth expression specifically in myocytes (MCK-Cre) or cardiomyocytes (Myh6-Cre). Mice lacking Fth in cardiomyocytes had decreased cardiac iron levels and increased oxidative stress, resulting in mild cardiac injury upon aging. However, feeding these mice a high-iron diet caused severe cardiac injury and hypertrophic cardiomyopathy, with molecular features typical of ferroptosis, including reduced glutathione (GSH) levels and increased lipid peroxidation. Ferrostatin-1, a specific inhibitor of ferroptosis, rescued this phenotype, supporting the notion that ferroptosis plays a pathophysiological role in the heart. Finally, we found that Fth-deficient cardiomyocytes have reduced expression of the ferroptosis regulator Slc7a11, and overexpressing Slc7a11 selectively in cardiomyocytes increased GSH levels and prevented cardiac ferroptosis. CONCLUSIONS Our findings provide compelling evidence that ferritin plays a major role in protecting against cardiac ferroptosis and subsequent heart failure, thereby providing a possible new therapeutic target for patients at risk of developing cardiomyopathy.
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Affiliation(s)
- Xuexian Fang
- From the First Affiliated Hospital, School of Public Health (X.F., Z.C., D.H., Q.C., P.Z., Y.Y., Z.S., Q.W., S.H., J.P., J.M., F.W.), Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China.,Beijing Advanced Innovation Center for Food Nutrition and Human Health, China Agricultural University (X.F., P.A., F.W.).,Department of Nutrition, Precision Nutrition Innovation Center, School of Public Health, Zhengzhou University, China (X.F., H.W., F.W.)
| | - Zhaoxian Cai
- From the First Affiliated Hospital, School of Public Health (X.F., Z.C., D.H., Q.C., P.Z., Y.Y., Z.S., Q.W., S.H., J.P., J.M., F.W.), Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Hao Wang
- Department of Nutrition, Precision Nutrition Innovation Center, School of Public Health, Zhengzhou University, China (X.F., H.W., F.W.)
| | - Dan Han
- From the First Affiliated Hospital, School of Public Health (X.F., Z.C., D.H., Q.C., P.Z., Y.Y., Z.S., Q.W., S.H., J.P., J.M., F.W.), Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Qi Cheng
- From the First Affiliated Hospital, School of Public Health (X.F., Z.C., D.H., Q.C., P.Z., Y.Y., Z.S., Q.W., S.H., J.P., J.M., F.W.), Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Pan Zhang
- From the First Affiliated Hospital, School of Public Health (X.F., Z.C., D.H., Q.C., P.Z., Y.Y., Z.S., Q.W., S.H., J.P., J.M., F.W.), Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Feng Gao
- The Second Affiliated Hospital (F.G., J.C.), Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Yingying Yu
- From the First Affiliated Hospital, School of Public Health (X.F., Z.C., D.H., Q.C., P.Z., Y.Y., Z.S., Q.W., S.H., J.P., J.M., F.W.), Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Zijun Song
- From the First Affiliated Hospital, School of Public Health (X.F., Z.C., D.H., Q.C., P.Z., Y.Y., Z.S., Q.W., S.H., J.P., J.M., F.W.), Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Qian Wu
- From the First Affiliated Hospital, School of Public Health (X.F., Z.C., D.H., Q.C., P.Z., Y.Y., Z.S., Q.W., S.H., J.P., J.M., F.W.), Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Peng An
- Beijing Advanced Innovation Center for Food Nutrition and Human Health, China Agricultural University (X.F., P.A., F.W.)
| | - Sicong Huang
- From the First Affiliated Hospital, School of Public Health (X.F., Z.C., D.H., Q.C., P.Z., Y.Y., Z.S., Q.W., S.H., J.P., J.M., F.W.), Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianwei Pan
- From the First Affiliated Hospital, School of Public Health (X.F., Z.C., D.H., Q.C., P.Z., Y.Y., Z.S., Q.W., S.H., J.P., J.M., F.W.), Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Hou-Zao Chen
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (H.-Z.C.)
| | - Jinghai Chen
- The Second Affiliated Hospital (F.G., J.C.), Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Andreas Linkermann
- Division of Nephrology, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany (A.L.)
| | - Junxia Min
- From the First Affiliated Hospital, School of Public Health (X.F., Z.C., D.H., Q.C., P.Z., Y.Y., Z.S., Q.W., S.H., J.P., J.M., F.W.), Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Fudi Wang
- From the First Affiliated Hospital, School of Public Health (X.F., Z.C., D.H., Q.C., P.Z., Y.Y., Z.S., Q.W., S.H., J.P., J.M., F.W.), Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China.,Beijing Advanced Innovation Center for Food Nutrition and Human Health, China Agricultural University (X.F., P.A., F.W.).,Department of Nutrition, Precision Nutrition Innovation Center, School of Public Health, Zhengzhou University, China (X.F., H.W., F.W.)
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12
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Doehner W, von Haehling S. Intravenous iron supplementation is state of the art therapy in patients with heart failure and iron deficiency. Eur J Heart Fail 2019; 21:1165. [PMID: 31116486 DOI: 10.1002/ejhf.1496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 12/28/2022] Open
Affiliation(s)
- Wolfram Doehner
- BCRT - Berlin Institute of Health Centre for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Centre, Göttingen, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
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