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Gharagozloo K, Mehdizadeh M, Heckman G, Rose RA, Howlett J, Howlett SE, Nattel S. Heart Failure With Preserved Ejection Fraction in the Elderly Population: Basic Mechanisms and Clinical Considerations. Can J Cardiol 2024; 40:1424-1444. [PMID: 38604339 DOI: 10.1016/j.cjca.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/04/2024] [Accepted: 04/06/2024] [Indexed: 04/13/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) refers to a clinical condition in which the signs of heart failure, such as pulmonary congestion, peripheral edema, and increased natriuretic peptide levels, are present despite normal ejection fractions and the absence of other causes (eg, pericardial disease). The ejection fraction cutoff for the definition of HFpEF has varied in the past, but recent society guidelines have settled on a consensus of 50%. HFpEF is particularly common in the elderly population. The aim of this narrative review is to summarize the available literature regarding HFpEF in elderly patients in terms of evidence for the age dependence, specific clinical features, and underlying mechanisms. In the clinical arena, we review the epidemiology, discuss distinct clinical phenotypes typically seen in elderly patients, the importance of frailty, the role of biomarkers, and the role of medical therapies (including sodium-glucose cotransport protein 2 inhibitors, renin-angiotensin-aldosterone system blockers, angiotensin receptor/neprilysin inhibitors, diuretics, and β-adrenergic receptor blockers). We then go on to discuss the basic mechanisms implicated in HFpEF, including cellular senescence, fibrosis, inflammation, mitochondrial dysfunction, enhanced production of reactive oxygen species, abnormal cellular calcium handling, changes in microRNA signalling, insulin resistance, and sex hormone changes. Finally, we review knowledge gaps and promising areas of future investigation. Improved understanding of the specific clinical manifestations of HFpEF in elderly individuals and of the fundamental mechanisms that contribute to the age-related risk of HFpEF promises to lead to novel diagnostic and treatment approaches that will improve outcomes for this common cardiac disorder in a vulnerable population.
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Affiliation(s)
- Kimia Gharagozloo
- Montreal Heart Institute Research Center and Université de Montréal, Montréal, Quebec, Canada; McGill University Departments of Pharmacology and Therapeutics, Montréal, Quebec, Canada
| | - Mozhdeh Mehdizadeh
- Montreal Heart Institute Research Center and Université de Montréal, Montréal, Quebec, Canada; McGill University Departments of Pharmacology and Therapeutics, Montréal, Quebec, Canada
| | - George Heckman
- Schlegel Research Institute for Aging and University of Waterloo, Waterloo, Ontario, Canada
| | - Robert A Rose
- Department of Cardiac Sciences, Department of Physiology and Pharmacology, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jonathan Howlett
- Libin Cardiovascular Institute and Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Susan E Howlett
- Departments of Pharmacology and Medicine (Geriatric Medicine), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Stanley Nattel
- Montreal Heart Institute Research Center and Université de Montréal, Montréal, Quebec, Canada; McGill University Departments of Pharmacology and Therapeutics, Montréal, Quebec, Canada; Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany.
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2
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Grigorescu ED, Lăcătușu CM, Floria M, Cazac GD, Onofriescu A, Sauciuc LA, Ceasovschih A, Crețu I, Mihai BM, Șorodoc L. Effects of Incretin-Based Treatment on the Diastolic (Dys)Function in Patients with Uncontrolled Type 2 Diabetes Mellitus: A Prospective Study with 1-Year Follow-Up. Diagnostics (Basel) 2023; 13:2817. [PMID: 37685355 PMCID: PMC10487011 DOI: 10.3390/diagnostics13172817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/19/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
Left ventricular diastolic dysfunction (DD) is a subclinical cardiac abnormality in patients with type 2 diabetes mellitus (T2DM) that can progress to heart failure (HF) and increase cardiovascular risk. This prospective study evaluated the DD in T2DM patients without atherosclerotic cardiovascular disease after one year of incretin-based drugs added to standard treatment. Of the 138 enrolled patients (49.30% male, mean age 57.86 ± 8.82, mean T2DM history 5 years), 71 were started on dipeptidyl peptidase-4 inhibitor sitagliptin/saxagliptin, 21 on glucagon-like peptide-1 receptor agonist exenatide, and 46 formed the control group (metformin and sulphonylurea/acarbose). At baseline, 71 patients had grade 1 DD, another 12 had grade 2 and 3 DD, and 15 had indeterminate DD. After one year, DD was evidenced in 50 cases. Diastolic function improved in 9 cases, and 27 patients went from grade 1 to indeterminate DD. The active group benefited more, especially patients treated with exenatide; their metabolic and inflammation profiles also improved the most. An in-depth analysis of echocardiographic parameters and paraclinical results in the context of literature data justifies the conclusion that early assessment of diastolic function in T2DM patients is necessary and the benefits of affordable incretin-based treatment may extend to subclinical cardiovascular manifestations such as DD.
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Affiliation(s)
- Elena-Daniela Grigorescu
- Unit of Diabetes, Nutrition and Metabolic Diseases, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (E.-D.G.); (A.O.); (B.-M.M.)
| | - Cristina-Mihaela Lăcătușu
- Unit of Diabetes, Nutrition and Metabolic Diseases, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (E.-D.G.); (A.O.); (B.-M.M.)
- Clinical Center of Diabetes, Nutrition and Metabolic Diseases, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Mariana Floria
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.F.); (A.C.); (L.Ș.)
- Medical Clinic, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Georgiana-Diana Cazac
- Unit of Diabetes, Nutrition and Metabolic Diseases, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (E.-D.G.); (A.O.); (B.-M.M.)
- Clinical Center of Diabetes, Nutrition and Metabolic Diseases, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Alina Onofriescu
- Unit of Diabetes, Nutrition and Metabolic Diseases, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (E.-D.G.); (A.O.); (B.-M.M.)
- Clinical Center of Diabetes, Nutrition and Metabolic Diseases, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Livia-Amira Sauciuc
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania;
| | - Alexandr Ceasovschih
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.F.); (A.C.); (L.Ș.)
- Medical Clinic, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Ioana Crețu
- Crețu R. Ioana PFA, 1 Mărului, 707020 Aroneanu, Romania;
| | - Bogdan-Mircea Mihai
- Unit of Diabetes, Nutrition and Metabolic Diseases, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (E.-D.G.); (A.O.); (B.-M.M.)
- Clinical Center of Diabetes, Nutrition and Metabolic Diseases, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Laurențiu Șorodoc
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (M.F.); (A.C.); (L.Ș.)
- Medical Clinic, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
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3
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Ladeiras-Lopes R, Sampaio F, Leite S, Santos-Ferreira D, Vilela E, Leite-Moreira A, Bettencourt N, Gama V, Braga P, Fontes-Carvalho R. Metformin in non-diabetic patients with metabolic syndrome and diastolic dysfunction: the MET-DIME randomized trial. Endocrine 2021; 72:699-710. [PMID: 33830437 DOI: 10.1007/s12020-021-02687-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/10/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE Metabolic syndrome (MetS) affects one out of 3 adults in the western world and is associated with preclinical diastolic dysfunction that impairs functional capacity and quality of life (QoL). This randomized trial was designed to evaluate if the addition of metformin to the standard treatment of non-diabetic patients with MetS improves diastolic dysfunction. METHODS Prospective, randomized, open-label, blinded-endpoint trial. Fifty-four non-diabetic adults with MetS and diastolic dysfunction were randomized to lifestyle counseling or lifestyle counseling plus metformin (target dose 1000 mg bid). The primary endpoint was the change in mean e' velocity (assessed at baseline, 6, 12 and 24 months). Secondary endpoints were improvements in insulin resistance, functional capacity and QoL. Linear mixed effects modeling was used for longitudinal data analysis using modified intention-to-treat (mITT) and per-protocol (PP) approaches. RESULTS Forty-nine patients were included in the mITT analysis (mean age = 51.8 ± 6.4; 55% males). Metformin treatment was associated with a significant decrease in HOMA-IR. There was a significantly different mean change in e' velocity during the study period between trial arms, both in the mITT (at 24 months, change of +0.67 ± 1.90 cm/s in metformin arm vs. -0.33 ± 1.50 cm/s in control arm) and PP populations (+0.80 ± 1.99 cm/s in metformin arm vs. -0.37 ± 1.52 cm/s in control arm), using a random intercept linear mixed model. There were no significant differences in peak oxygen uptake and SF-36 scores between trial arms. CONCLUSIONS Treatment with metformin of non-diabetic MetS patients with diastolic dysfunction, on top of lifestyle counseling, is associated with improved diastolic function.
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Affiliation(s)
- Ricardo Ladeiras-Lopes
- Cardiology Department, Gaia Hospital Centre, Vila Nova de Gaia, Portugal.
- Cardiovascular Research and Development Centre, Faculty of Medicine of the University of Porto, Porto, Portugal.
| | - Francisco Sampaio
- Cardiology Department, Gaia Hospital Centre, Vila Nova de Gaia, Portugal
- Cardiovascular Research and Development Centre, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Sara Leite
- Cardiovascular Research and Development Centre, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Diogo Santos-Ferreira
- Cardiology Department, Gaia Hospital Centre, Vila Nova de Gaia, Portugal
- Cardiovascular Research and Development Centre, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Eduardo Vilela
- Cardiology Department, Gaia Hospital Centre, Vila Nova de Gaia, Portugal
| | - Adelino Leite-Moreira
- Cardiology Department, Gaia Hospital Centre, Vila Nova de Gaia, Portugal
- Cardiovascular Research and Development Centre, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Nuno Bettencourt
- Cardiology Department, Gaia Hospital Centre, Vila Nova de Gaia, Portugal
- Cardiovascular Research and Development Centre, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Vasco Gama
- Cardiology Department, Gaia Hospital Centre, Vila Nova de Gaia, Portugal
| | - Pedro Braga
- Cardiology Department, Gaia Hospital Centre, Vila Nova de Gaia, Portugal
| | - Ricardo Fontes-Carvalho
- Cardiology Department, Gaia Hospital Centre, Vila Nova de Gaia, Portugal
- Cardiovascular Research and Development Centre, Faculty of Medicine of the University of Porto, Porto, Portugal
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4
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Gopal K, Chahade JJ, Kim R, Ussher JR. The Impact of Antidiabetic Therapies on Diastolic Dysfunction and Diabetic Cardiomyopathy. Front Physiol 2020; 11:603247. [PMID: 33364978 PMCID: PMC7750477 DOI: 10.3389/fphys.2020.603247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022] Open
Abstract
Diabetic cardiomyopathy is more prevalent in people with type 2 diabetes mellitus (T2DM) than previously recognized, while often being characterized by diastolic dysfunction in the absence of systolic dysfunction. This likely contributes to why heart failure with preserved ejection fraction is enriched in people with T2DM vs. heart failure with reduced ejection fraction. Due to revised mandates from major health regulatory agencies, all therapies being developed for the treatment of T2DM must now undergo rigorous assessment of their cardiovascular risk profiles prior to approval. As such, we now have data from tens of thousands of subjects with T2DM demonstrating the impact of major therapies including the sodium-glucose co-transporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 receptor (GLP-1R) agonists, and dipeptidyl peptidase 4 (DPP-4) inhibitors on cardiovascular outcomes. Evidence to date suggests that both SGLT2 inhibitors and GLP-1R agonists improve cardiovascular outcomes, whereas DPP-4 inhibitors appear to be cardiovascular neutral, though evidence is lacking to determine the overall utility of these therapies on diastolic dysfunction or diabetic cardiomyopathy in subjects with T2DM. We herein will review the overall impact SLGT2 inhibitors, GLP-1R agonists, and DPP-4 inhibitors have on major parameters of diastolic function, while also highlighting the potential mechanisms of action responsible. A more complete understanding of how these therapies influence diastolic dysfunction will undoubtedly play a major role in how we manage cardiovascular disease in subjects with T2DM.
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Affiliation(s)
- Keshav Gopal
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada.,Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada.,Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada
| | - Jadin J Chahade
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada.,Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada.,Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada
| | - Ryekjang Kim
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada.,Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada.,Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada
| | - John R Ussher
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada.,Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada.,Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada
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5
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Association between long-term prescription of metformin and the progression of heart failure with preserved ejection fraction in patients with type 2 diabetes mellitus and hypertension. Int J Cardiol 2020; 306:140-145. [DOI: 10.1016/j.ijcard.2019.11.087] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/26/2019] [Accepted: 11/06/2019] [Indexed: 12/19/2022]
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6
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Ladeiras-Lopes R, Teixeira P, Azevedo A, Leite-Moreira A, Bettencourt N, Fontes-Carvalho R. Metabolic syndrome severity score is associated with diastolic dysfunction and low-grade inflammation in a community-based cohort. Eur J Prev Cardiol 2019; 27:2330-2333. [PMID: 31847564 DOI: 10.1177/2047487319895400] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Ricardo Ladeiras-Lopes
- Serviço de Cardiologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.,Unidade de Investigação e Desenvolvimento Cardiovascular, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Pedro Teixeira
- Serviço de Cardiologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.,Unidade de Investigação e Desenvolvimento Cardiovascular, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Ana Azevedo
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.,Departamento de Ciências da Saúde Pública e Forenses, e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Adelino Leite-Moreira
- Unidade de Investigação e Desenvolvimento Cardiovascular, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Nuno Bettencourt
- Unidade de Investigação e Desenvolvimento Cardiovascular, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Ricardo Fontes-Carvalho
- Serviço de Cardiologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.,Unidade de Investigação e Desenvolvimento Cardiovascular, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
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7
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Warbrick I, Rabkin SW. Hypoxia-inducible factor 1-alpha (HIF-1α) as a factor mediating the relationship between obesity and heart failure with preserved ejection fraction. Obes Rev 2019; 20:701-712. [PMID: 30828970 DOI: 10.1111/obr.12828] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/31/2018] [Accepted: 08/02/2018] [Indexed: 12/17/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF), a common condition with an increased mortality, is strongly associated with obesity and the metabolic syndrome. The latter two conditions are associated with increased epicardial fat that can extend into the heart. This review advances the proposition that hypoxia-inhibitory factor-1α (HIF-1α) maybe a key factor producing HFpEF. HIF-1α, a highly conserved transcription factor that plays a key role in tissue response to hypoxia, is increased in adipose tissue in obesity. Increased HIF-1α expression leads to expression of a potent profibrotic transcriptional programme involving collagen I, III, IV, TIMP, and lysyl oxidase. The net effect is the formation of collagen fibres leading to fibrosis. HIF-1α is also responsible for recruiting M1 macrophages that mediate obesity-associated inflammation, releasing IL-6, MCP-1, TNF-α, and IL-1β with increased expression of thrombospondin, pro α2 (I) collagen, transforming growth factor β, NADPH oxidase, and connective tissue growth factor. These factors can accelerate cardiac fibrosis and impair cardiac diastolic function. Inhibition of HIF-1α expression in adipose tissue of mice fed a high-fat diet suppressed fibrosis and reduces inflammation in adipose tissue. Delineation of the role played by HIF-1α in obesity-associated HFpEF may lead to new potential therapies.
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Affiliation(s)
- Ian Warbrick
- Department of Medicine (Cardiology), University of British Columbia, Vancouver, Canada
| | - Simon W Rabkin
- Department of Medicine (Cardiology), University of British Columbia, Vancouver, Canada
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Slater RE, Strom JG, Methawasin M, Liss M, Gotthardt M, Sweitzer N, Granzier HL. Metformin improves diastolic function in an HFpEF-like mouse model by increasing titin compliance. J Gen Physiol 2018; 151:42-52. [PMID: 30567709 PMCID: PMC6314384 DOI: 10.1085/jgp.201812259] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/14/2018] [Indexed: 12/20/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a syndrome characterized by increased diastolic stiffness, for which effective therapies are lacking. Slater et al. show that metformin lowers titin-based passive stiffness in an HFpEF mouse model and may therefore be of therapeutic benefit. Heart failure with preserved ejection fraction (HFpEF) is a complex syndrome characterized by a preserved ejection fraction but increased diastolic stiffness and abnormalities of filling. Although the prevalence of HFpEF is high and continues to rise, no effective therapies exist; however, the diabetic drug metformin has been associated with improved diastolic function in diabetic patients. Here we determine the therapeutic potential of metformin for improving diastolic function in a mouse model with HFpEF-like symptoms. We combine transverse aortic constriction (TAC) surgery with deoxycorticosterone acetate (DOCA) supplementation to obtain a mouse model with increased diastolic stiffness and exercise intolerance. Echocardiography and pressure–volume analysis reveal that providing metformin to TAC/DOCA mice improves diastolic function in the left ventricular (LV) chamber. Muscle mechanics show that metformin lowers passive stiffness of the LV wall muscle. Concomitant with this improvement in diastolic function, metformin-treated TAC/DOCA mice also demonstrate preserved exercise capacity. No metformin effects are seen in sham operated mice. Extraction experiments on skinned ventricular muscle strips show that the metformin-induced reduction of passive stiffness in TAC/DOCA mice is due to an increase in titin compliance. Using phospho-site-specific antibodies, we assay the phosphorylation of titin’s PEVK and N2B spring elements. Metformin-treated mice have unaltered PEVK phosphorylation but increased phosphorylation of PKA sites in the N2B element, a change which has previously been shown to lower titin’s stiffness. Consistent with this result, experiments with a mouse model deficient in the N2B element reveal that the beneficial effect of metformin on LV chamber and muscle stiffness requires the presence of the N2B element. We conclude that metformin offers therapeutic benefit during HFpEF by lowering titin-based passive stiffness.
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Affiliation(s)
- Rebecca E Slater
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson, AZ
| | - Joshua G Strom
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson, AZ
| | - Mei Methawasin
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson, AZ
| | - Martin Liss
- Neuromuscular and Cardiovascular Cell Biology, Max Delbrück Center for Molecular Medicine, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Michael Gotthardt
- Neuromuscular and Cardiovascular Cell Biology, Max Delbrück Center for Molecular Medicine, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Nancy Sweitzer
- Sarver Heart Center, College of Medicine, University of Arizona, Tucson, AZ
| | - Henk L Granzier
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson, AZ .,Sarver Heart Center, College of Medicine, University of Arizona, Tucson, AZ
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9
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Al Ali L, Hartman MT, Lexis CPH, Hummel YM, Lipsic E, van Melle JP, van Veldhuisen DJ, Voors AA, van der Horst ICC, van der Harst P. The Effect of Metformin on Diastolic Function in Patients Presenting with ST-Elevation Myocardial Infarction. PLoS One 2016; 11:e0168340. [PMID: 27977774 PMCID: PMC5158040 DOI: 10.1371/journal.pone.0168340] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 11/24/2016] [Indexed: 12/28/2022] Open
Abstract
Introduction Diastolic dysfunction is an important predictor of poor outcome after myocardial infarction. Metformin treatment improved diastolic function in animal models and patients with diabetes. Whether metformin improves diastolic function in patients presenting with ST-segment elevation myocardial infarction (STEMI) is unknown. Methods The GIPS-III trial randomized STEMI patients, without known diabetes, to metformin or placebo initiated directly after PCI. The previously reported primary endpoint was left ventricular ejection fraction at 4 months, which was unaffected by metformin treatment. This is a predefined substudy to determine an effect of metformin on diastolic function. For this substudy trans-thoracic echocardiography was performed during hospitalization and after 4 months. Diastolic dysfunction was defined as having the combination of a functional alteration (i.e. decreased tissue velocity: mean of septal e’ and lateral e’) and a structural alteration (i.e. increased left atrial volume index (LAVI)). In addition, left ventricular mass index and transmitral flow velocity (E) to mean e' ratio (E/e’) were measured to determine an effect of metformin on individual echocardiographic markers of diastolic function. Results In 237 (63%) patients included in the GIPS-III trial diastolic function was measured during hospitalization as well as at 4 months. Diastolic dysfunction was present in 11 (9%) of patients on metformin and 11 (9%) patients on placebo treatment (P = 0.98) during hospitalization. After 4 months 22 (19%) of patients with metformin and 18 (15%) patients with placebo (P = 0.47) had diastolic dysfunction. In addition, metformin did not improve any of the individual echocardiographic markers of diastolic function. Conclusions In contrast to experimental and observational data, our randomized placebo controlled trial did not suggest a beneficial effect of short-term metformin treatment on diastolic function in STEMI patients.
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Affiliation(s)
- Lawien Al Ali
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Minke T. Hartman
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Chris P. H. Lexis
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Yoran M. Hummel
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Erik Lipsic
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Joost P. van Melle
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Dirk J. van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Adriaan A. Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Iwan C. C. van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Pim van der Harst
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- * E-mail:
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10
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Cadeddu C, Nocco S, Cugusi L, Deidda M, Fabio O, Bandino S, Cossu E, Incani M, Baroni MG, Mercuro G. Effects of Metformin and Exercise Training, Alone or in Combination, on Cardiac Function in Individuals with Insulin Resistance. Cardiol Ther 2016; 5:63-73. [PMID: 26831122 PMCID: PMC4906084 DOI: 10.1007/s40119-016-0057-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Indexed: 01/30/2023] Open
Abstract
Introduction In patients affected by insulin resistance (IR), metformin (MET) therapy has been shown to exert its positive effects by improving glucose tolerance and preventing the evolution to diabetes. Recently, it was shown that the addition of metformin to physical training did not improve sensitivity to insulin or peak oxygen consumption (peak VO2). The purpose of this study was to establish the effect of metformin and exercise, separately or in combination, on systolic left ventricular (LV) function in individuals with IR. Methods Seventy-five patients with IR were enrolled and subsequently assigned to MET, combination MET and exercise, or exercise alone. The LV systolic and diastolic functions were evaluated with standard echocardiography tissue Doppler imaging (TDI) and speckle tracking echocardiography at baseline and after 12 weeks of treatment. Results MET, administered alone or in association with exercise, improved longitudinal LV function, as evidenced by an increase in systolic (S) wave on TDI, alongside increases in longitudinal global strain and strain rate in comparison to the group undergoing physical training alone. The traditional echocardiographic parameters showed no statistically significant differences among the three groups before or after the different cycles of therapy. Conclusions Treatment with MET, either with or without exercise, but not exercise alone, produced a significant increase in global longitudinal LV systolic function at rest. These findings validate the observation that the use of MET alone or in association with exercise has a crucial role to counteract the negative effects of IR on cardiovascular function. Electronic supplementary material The online version of this article (doi:10.1007/s40119-016-0057-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christian Cadeddu
- Department of Medical Sciences "M Aresu", University of Cagliari, Strada Statale 554, Km 4.500, 09042, Monserrato, CA, Italy
| | - Silvio Nocco
- Department of Medical Sciences "M Aresu", University of Cagliari, Strada Statale 554, Km 4.500, 09042, Monserrato, CA, Italy.
| | - Lucia Cugusi
- Department of Medical Sciences "M Aresu", University of Cagliari, Strada Statale 554, Km 4.500, 09042, Monserrato, CA, Italy
| | - Martino Deidda
- Department of Medical Sciences "M Aresu", University of Cagliari, Strada Statale 554, Km 4.500, 09042, Monserrato, CA, Italy
| | - Orru Fabio
- Department of Medical Sciences "M Aresu", University of Cagliari, Strada Statale 554, Km 4.500, 09042, Monserrato, CA, Italy
| | - Stefano Bandino
- Department of Medical Sciences "M Aresu", University of Cagliari, Strada Statale 554, Km 4.500, 09042, Monserrato, CA, Italy
| | - Efisio Cossu
- Department of Medical Sciences "M Aresu", University of Cagliari, Strada Statale 554, Km 4.500, 09042, Monserrato, CA, Italy
| | - Michela Incani
- Department of Medical Sciences "M Aresu", University of Cagliari, Strada Statale 554, Km 4.500, 09042, Monserrato, CA, Italy
| | - Marco Giorgio Baroni
- Department of Medical Sciences "M Aresu", University of Cagliari, Strada Statale 554, Km 4.500, 09042, Monserrato, CA, Italy
| | - Giuseppe Mercuro
- Department of Medical Sciences "M Aresu", University of Cagliari, Strada Statale 554, Km 4.500, 09042, Monserrato, CA, Italy
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11
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D'Elia E, Vaduganathan M, Gori M, Gavazzi A, Butler J, Senni M. Role of biomarkers in cardiac structure phenotyping in heart failure with preserved ejection fraction: critical appraisal and practical use. Eur J Heart Fail 2015; 17:1231-9. [PMID: 26493383 DOI: 10.1002/ejhf.430] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 09/28/2015] [Accepted: 09/28/2015] [Indexed: 12/28/2022] Open
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) is a heterogeneous clinical syndrome characterized by cardiovascular, metabolic, and pro-inflammatory diseases associated with advanced age and extracardiac comorbidities. All of these conditions finally lead to impairment of myocardial structure and function. The large phenotypic heterogeneity of HFpEF from pathophysiological underpinnings presents a major hurdle to HFpEF therapy. The new therapeutic approach in HFpEF should be targeted to each HF phenotype, instead of the 'one-size-fits-all' approach, which has not been successful in clinical trials. Unless the structural and biological determinants of the failing heart are deeply understood, it will be impossible to appropriately differentiate HFpEF patients, identify subtle myocardial abnormalities, and finally reverse abnormal cardiac function. Based on evidence from endomyocardial biopsies, some of the specific cardiac structural phenotypes to be targeted in HFpEF may be represented by myocyte hypertrophy, interstitial fibrosis, myocardial inflammation associated with oxidative stress, and coronary disease. Once the diagnosis of HFpEF has been established, a potential approach could be to use a panel of biomarkers to identify the main cardiac structural HFpEF phenotypes, guiding towards more appropriate therapeutic strategies. Accordingly, the purpose of this review is to investigate the potential role of biomarkers in identifying different cardiac structural HFpEF phenotypes and to discuss the merits of a biomarker-guided strategy in HFpEF.
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Affiliation(s)
- Emilia D'Elia
- Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Mauro Gori
- Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Antonello Gavazzi
- FROM Fondazione per la Ricerca, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Javed Butler
- Cardiology Division, Stony Brook University, Stony Brook, NY, USA
| | - Michele Senni
- Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
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12
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Schilling JD. The mitochondria in diabetic heart failure: from pathogenesis to therapeutic promise. Antioxid Redox Signal 2015; 22:1515-26. [PMID: 25761843 PMCID: PMC4449623 DOI: 10.1089/ars.2015.6294] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
SIGNIFICANCE Diabetes is an important risk factor for the development of heart failure (HF). Given the increasing prevalence of diabetes in the population, strategies are needed to reduce the burden of HF in these patients. RECENT ADVANCES Diabetes is associated with several pathologic findings in the heart including dysregulated metabolism, lipid accumulation, oxidative stress, and inflammation. Emerging evidence suggests that mitochondrial dysfunction may be a central mediator of these pathologic responses. The development of therapeutic approaches targeting mitochondrial biology holds promise for the management of HF in diabetic patients. CRITICAL ISSUES Despite significant data implicating mitochondrial pathology in diabetic cardiomyopathy, the optimal pharmacologic approach to improve mitochondrial function remains undefined. FUTURE DIRECTIONS Detailed mechanistic studies coupled with more robust clinical phenotyping will be necessary to develop novel approaches to improve cardiac function in diabetes. Moreover, understanding the interplay between diabetes and other cardiac stressors (hypertension, ischemia, and valvular disease) will be of the utmost importance for clinical translation of scientific discoveries made in this field.
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Affiliation(s)
- Joel D Schilling
- 1Diabetic Cardiovascular Disease Center, Washington University School of Medicine, St. Louis, Missouri.,2Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.,3Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
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13
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Ladeiras-Lopes R, Fontes-Carvalho R, Bettencourt N, Sampaio F, Gama V, Leite-Moreira A. Novel therapeutic targets of metformin: metabolic syndrome and cardiovascular disease. Expert Opin Ther Targets 2015; 19:869-77. [DOI: 10.1517/14728222.2015.1025051] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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14
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Fontes-Carvalho R, Ladeiras-Lopes R, Bettencourt P, Leite-Moreira A, Azevedo A. Diastolic dysfunction in the diabetic continuum: association with insulin resistance, metabolic syndrome and type 2 diabetes. Cardiovasc Diabetol 2015; 14:4. [PMID: 25582424 PMCID: PMC4298953 DOI: 10.1186/s12933-014-0168-x] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 12/27/2014] [Indexed: 12/14/2022] Open
Abstract
Background Diabetes increases the risk of heart failure but the underlying mechanisms leading to diabetic cardiomyopathy are poorly understood. Left ventricle diastolic dysfunction (LVDD) is one of the earliest cardiac changes in these patients. We aimed to evaluate the association between LVDD with insulin resistance, metabolic syndrome (MS) and diabetes, across the diabetic continuum. Methods Within a population-based study (EPIPorto), a total of 1063 individuals aged ≥45 years (38% male, 61.2 ± 9.6 years) were evaluated. Diastolic function was assessed by echocardiography, using tissue Doppler analysis (E’ velocity and E/E’ ratio) according to the latest consensus guidelines. Insulin resistance was assessed using the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) score. Results The HOMA-IR score correlated to E’ velocity (ρ = −0.20;p < 0.0001) and E/E’ ratio (ρ = 0.20; p < 0.0001). There was a progressive worsening in E’ velocity (p for trend < 0.001) and in E/E’ ratio across HOMA-IR quartiles (p for trend <0.001). Individuals in the highest HOMA-IR quartile were more likely to have LVDD, even after adjustment for age, sex, blood pressure and body mass index (adjusted OR: 1.82; 95% CI: 1.09-3.03). From individuals with no MS, to patients with MS and no diabetes, to patients with diabetes, there was a progressive decrease in E’ velocity (11.2 ± 3.3 vs 9.7 ± 3.1 vs 9.2 ± 2.8 cm/s; p < 0.0001), higher E/E’ (6.9 ± 2.3 vs 7.8 ± 2.7 vs 9.0 ± 3.6; p < 0.0001) and more diastolic dysfunction (adjusted OR: 1.62; 95% CI: 1.12-2.36 and 1.78; 95% CI: 1.09-2.91, respectively). Conclusions HOMA-IR score and metabolic syndrome were independently associated with LVDD. Changes in diastolic function are already present before the onset of diabetes, being mainly associated with the state of insulin resistance. Electronic supplementary material The online version of this article (doi:10.1186/s12933-014-0168-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ricardo Fontes-Carvalho
- EPIUnit - Institute of Public Health, University of Porto, Porto, Portugal. .,Cardiology Department, Gaia Hospital Center, Vila Nova Gaia, Portugal. .,Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Ricardo Ladeiras-Lopes
- Cardiology Department, Gaia Hospital Center, Vila Nova Gaia, Portugal. .,Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Paulo Bettencourt
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal. .,Department of Internal Medicine, Centro Hospitalar São João, Porto, Portugal.
| | - Adelino Leite-Moreira
- Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Porto, Portugal. .,Department of Cardiothoracic Surgery, Centro Hospitalar São João, Porto, Portugal.
| | - Ana Azevedo
- EPIUnit - Institute of Public Health, University of Porto, Porto, Portugal. .,Department of Clinical Epidemiology, Predictive Medicine and Public Health, Faculty of Medicine, University of Porto, Porto, Portugal.
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15
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Schilling JD, Mann DL. Diabetic Cardiomyopathy: Distinct and Preventable Entity or Inevitable Consequence? CURRENT CARDIOVASCULAR RISK REPORTS 2014. [DOI: 10.1007/s12170-014-0417-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Bostick B, Habibi J, Ma L, Aroor A, Rehmer N, Hayden MR, Sowers JR. Dipeptidyl peptidase inhibition prevents diastolic dysfunction and reduces myocardial fibrosis in a mouse model of Western diet induced obesity. Metabolism 2014; 63:1000-11. [PMID: 24933400 PMCID: PMC4128682 DOI: 10.1016/j.metabol.2014.04.002] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 04/04/2014] [Accepted: 04/04/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Consumption of a high-fat/high-fructose Western diet (WD) is linked to rising obesity and heart disease, particularly diastolic dysfunction which characterizes early obesity/metabolic cardiomyopathy. Mounting evidence supports a role for inflammation, oxidative stress and fibrosis in the pathophysiology of metabolic cardiomyopathy. Dipeptidyl peptidase-4 (DPP-4) is a circulating exopeptidase recently reported to be elevated in the plasma of patients with insulin resistance (IR), obesity and heart failure. We hypothesized that a model of WD induced obesity/metabolic cardiomyopathy would exhibit increased DPP-4 activity and cardiac fibrosis with DPP-4 inhibition preventing cardiac fibrosis and the associated diastolic dysfunction. MATERIALS/METHODS Four-week-old C57BL6/J mice were fed a high-fat/high-fructose WD with the DPP-4 inhibitor MK0626 for 16 weeks. Cardiac function was examined by high-resolution cine-cardiac magnetic resonance imaging (MRI). Phenotypic analysis included measurements of body and heart weight, systemic IR and DPP-4 activity. Immunohistochemistry and transmission electron microscopy (TEM) were utilized to identify underlying pathologic mechanisms. RESULTS We found that chronic WD consumption caused obesity, IR, elevated plasma DPP-4 activity, heart enlargement and diastolic dysfunction. DPP-4 inhibition with MK0626 in WD fed mice resulted in >75% reduction in plasma DPP-4 activity, improved IR and normalized diastolic relaxation. WD consumption induced myocardial oxidant stress and fibrosis with amelioration by MK0626. TEM of hearts from WD fed mice revealed abnormal mitochondrial and perivascular ultrastructure partially corrected by MK0626. CONCLUSIONS This study provides evidence of a role for increased DPP-4 activity in metabolic cardiomyopathy and a potential role for DPP-4 inhibition in prevention and/or correction of oxidant stress/fibrosis and associated diastolic dysfunction.
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Affiliation(s)
- Brian Bostick
- Division of Cardiovascular Medicine, Diabetes Cardiovascular Center, University of Missouri, Columbia, MO, USA; Department of Medicine, University of Missouri, Columbia, MO, USA; Harry S. Truman Memorial Veterans Hospital, Columbia MO, USA
| | - Javad Habibi
- Department of Medicine, University of Missouri, Columbia, MO, USA; Harry S. Truman Memorial Veterans Hospital, Columbia MO, USA; Division of Endocrinology and Metabolism, Diabetes Cardiovascular Center, University of Missouri, Columbia, MO, USA
| | - Lixin Ma
- Harry S. Truman Memorial Veterans Hospital, Columbia MO, USA; Department of Radiology, University of Missouri, Columbia, MO, USA
| | - Annayya Aroor
- Department of Medicine, University of Missouri, Columbia, MO, USA; Harry S. Truman Memorial Veterans Hospital, Columbia MO, USA; Division of Endocrinology and Metabolism, Diabetes Cardiovascular Center, University of Missouri, Columbia, MO, USA
| | - Nathan Rehmer
- Department of Medicine, University of Missouri, Columbia, MO, USA; Harry S. Truman Memorial Veterans Hospital, Columbia MO, USA; Division of Endocrinology and Metabolism, Diabetes Cardiovascular Center, University of Missouri, Columbia, MO, USA
| | - Melvin R Hayden
- Department of Medicine, University of Missouri, Columbia, MO, USA; Harry S. Truman Memorial Veterans Hospital, Columbia MO, USA; Division of Endocrinology and Metabolism, Diabetes Cardiovascular Center, University of Missouri, Columbia, MO, USA
| | - James R Sowers
- Department of Medicine, University of Missouri, Columbia, MO, USA; Harry S. Truman Memorial Veterans Hospital, Columbia MO, USA; Division of Endocrinology and Metabolism, Diabetes Cardiovascular Center, University of Missouri, Columbia, MO, USA; Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, MO, USA.
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