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Sun Y, Li J, Zhang X, Wang N, Liu Y. RNA Sequencing Screens the Key Genes and Pathways in a Mouse Model of HFpEF. J Vasc Res 2024:1-13. [PMID: 38880090 DOI: 10.1159/000539305] [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: 11/10/2023] [Accepted: 05/02/2024] [Indexed: 06/18/2024] Open
Abstract
INTRODUCTION Heart failure with preserved ejection fraction (HFpEF) is a common syndrome with high morbidity and mortality but without available evidence-based therapies. It is essential to investigate changes in gene expression profiles in preclinical HFpEF animal models, with the aim of searching for novel therapeutic targets. METHODS Wild-type male C57BL/6J mice were administrated with a combination of high-fat diet (HFD) and inhibition of constitutive nitric oxide synthase using N-nitro-l-arginine methyl ester (l-NAME) for 5 and 7 weeks. RNA sequencing was conducted to detect gene expression profiles, and bioinformatic analysis was performed to identify the core genes, pathways, and biological processes involved. RESULTS A total of 1,347 genes were differentially expressed in the heart at week 5 and 7 post-intervention. Gene Ontology enrichment analysis indicated that these greatly changed genes were involved mainly in cell adhesion, neutrophil chemotaxis, cell communication, and other functions. Using hierarchical cluster analysis, these differentially expressed genes were classified into 16 profiles. Of these, three significant profiles were ultimately identified. Gene co-expression network analysis suggested troponin T type 1 (Tnnt1) directly regulated 31 neighboring genes and was considered to be at the core of the associated gene network. CONCLUSION The combined application of RNA sequencing, hierarchical cluster analysis, and gene network analysis identified Tnnt1 as the most important gene in the development of HFpEF.
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Affiliation(s)
- Yuxi Sun
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China,
| | - Jiaxin Li
- Heart Failure and Structural Cardiology Division, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xinxin Zhang
- Heart Failure and Structural Cardiology Division, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ning Wang
- Heart Failure and Structural Cardiology Division, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ying Liu
- Heart Failure and Structural Cardiology Division, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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Xia W, Zhang M, Liu C, Wang S, Xu A, Xia Z, Pang L, Cai Y. Exploring the therapeutic potential of tetrahydrobiopterin for heart failure with preserved ejection fraction: A path forward. Life Sci 2024; 345:122594. [PMID: 38537900 DOI: 10.1016/j.lfs.2024.122594] [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: 01/17/2024] [Revised: 03/10/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Abstract
A large number of patients are affected by classical heart failure (HF) symptomatology with preserved ejection fraction (HFpEF) and multiorgan syndrome. Due to high morbidity and mortality rate, hospitalization and mortality remain serious socioeconomic problems, while the lack of effective pharmacological or device treatment means that HFpEF presents a major unmet medical need. Evidence from clinical and basic studies demonstrates that systemic inflammation, increased oxidative stress, and impaired mitochondrial function are the common pathological mechanisms in HFpEF. Tetrahydrobiopterin (BH4), beyond being an endogenous co-factor for catalyzing the conversion of some essential biomolecules, has the capacity to prevent systemic inflammation, enhance antioxidant resistance, and modulate mitochondrial energy production. Therefore, BH4 has emerged in the last decade as a promising agent to prevent or reverse the progression of disorders such as cardiovascular disease. In this review, we cover the clinical progress and limitations of using downstream targets of nitric oxide (NO) through NO donors, soluble guanylate cyclase activators, phosphodiesterase inhibitors, and sodium-glucose co-transporter 2 inhibitors in treating cardiovascular diseases, including HFpEF. We discuss the use of BH4 in association with HFpEF, providing new evidence for its potential use as a pharmacological option for treating HFpEF.
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Affiliation(s)
- Weiyi Xia
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Miao Zhang
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong SAR, China; Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Guangdong, China
| | - Chang Liu
- Department of Anesthesiology, The First Hospital of Jilin University, Jilin, China
| | - Sheng Wang
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Aimin Xu
- State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Hong Kong SAR, China; Department of Medicine, The University of Hong Kong, Hong Kong SAR, China; Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Zhengyuan Xia
- Department of Anesthesiology, Affiliated Hospital of Guangdong Medical University, Guangdong, China
| | - Lei Pang
- Department of Anesthesiology, The First Hospital of Jilin University, Jilin, China.
| | - Yin Cai
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong SAR, China; Research Center for Chinese Medicine Innovation, The Hong Kong Polytechnic University, Hong Kong SAR, China; Research Institute for Future Food, The Hong Kong Polytechnic University, Hong Kong SAR, China.
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3
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Zhang X, Wang N, Fu P, An Y, Sun F, Wang C, Han X, Zhang Y, Yu X, Liu Y. Dapagliflozin Attenuates Heart Failure With Preserved Ejection Fraction Remodeling and Dysfunction by Elevating β-Hydroxybutyrate-activated Citrate Synthase. J Cardiovasc Pharmacol 2023; 82:375-388. [PMID: 37643027 PMCID: PMC10635406 DOI: 10.1097/fjc.0000000000001474] [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] [Received: 03/17/2023] [Accepted: 08/07/2023] [Indexed: 08/31/2023]
Abstract
ABSTRACT Heart failure with preserved ejection fraction (HFpEF) is highly prevalent, accounting for 50% of all heart failure patients, and is associated with significant mortality. Sodium-glucose cotransporter subtype inhibitor (SGLT2i) is recommended in the AHA and ESC guidelines for the treatment of HFpEF, but the mechanism of SGLT2i to prevent and treat cardiac remodeling and dysfunction is currently unknown, hindering the understanding of the pathophysiology of HFpEF and the development of novel therapeutics. HFpEF model was induced by a high-fat diet (60% calories from lard) + N [w] -nitro- l -arginine methyl ester ( l -NAME-0.5 g/L) (2 Hit) in male Sprague Dawley rats to effectively recapture the myriad phenotype of HFpEF. This study's results showed that administration of dapagliflozin (DAPA, SGLT2 inhibitor) significantly limited the 2-Hit-induced cardiomyocyte hypertrophy, apoptosis, inflammation, oxidative stress, and fibrosis. It also improved cardiac diastolic and systolic dysfunction in a late-stage progression of HFpEF. Mechanistically, DAPA influences energy metabolism associated with fatty acid intake and mitochondrial dysfunction in HFpEF by increasing β-hydroxybutyric acid (β-OHB) levels, directing the activation of citrate synthase, reducing acetyl coenzyme A (acetyl-CoA) pools, modulating adenosine 5'-triphosphate production, and increasing the expression of mitochondrial oxidative phosphorylation system complexes I-V. In addition, following clinical DAPA therapy, the blood levels of β-OHB and citrate synthase increased and the levels of acetyl-CoA in the blood of HFpEF patients decreased. SGLT2i plays a beneficial role in the prevention and treatment of cardiac remodeling and dysfunction in HFpEF model by attenuating cardiometabolic dysregulation.
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Affiliation(s)
- Xinxin Zhang
- Department of Cardiology, Institute of Cardiovascular Diseases
| | - Ning Wang
- Department of Cardiology, Institute of Cardiovascular Diseases
| | - Peng Fu
- Department of Cardiology, Institute of Cardiovascular Diseases
| | - Yanliang An
- Department of Cardiology, Institute of Cardiovascular Diseases
| | - Fangfang Sun
- Department of Nuclear Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China; and
| | - Chengdong Wang
- Department of Nuclear Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China; and
| | - Xiao Han
- Department of Emergency Medicine, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yunlong Zhang
- Department of Emergency Medicine, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xiaohong Yu
- Department of Cardiology, Institute of Cardiovascular Diseases
| | - Ying Liu
- Department of Cardiology, Institute of Cardiovascular Diseases
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4
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Balmain BN, Tomlinson AR, MacNamara JP, Hynan LS, Wakeham DJ, Levine BD, Sarma S, Babb TG. Reducing Pulmonary Capillary Wedge Pressure During Exercise Exacerbates Exertional Dyspnea in Patients With Heart Failure With Preserved Ejection Fraction: Implications for V˙/Q˙ Mismatch. Chest 2023; 164:686-699. [PMID: 37030529 PMCID: PMC10548458 DOI: 10.1016/j.chest.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/29/2023] [Accepted: 04/01/2023] [Indexed: 04/09/2023] Open
Abstract
BACKGROUND The primary cause of dyspnea on exertion in heart failure with preserved ejection fraction (HFpEF) is presumed to be the marked rise in pulmonary capillary wedge pressure during exercise; however, this hypothesis has never been tested directly. Therefore, we evaluated invasive exercise hemodynamics and dyspnea on exertion in patients with HFpEF before and after acute nitroglycerin (NTG) treatment to lower pulmonary capillary wedge pressure. RESEARCH QUESTION Does reducing pulmonary capillary wedge pressure during exercise with NTG improve dyspnea on exertion in HFpEF? STUDY DESIGN AND METHODS Thirty patients with HFpEF performed two invasive 6-min constant-load cycling tests (20 W): one with placebo (PLC) and one with NTG. Ratings of perceived breathlessness (0-10 scale), pulmonary capillary wedge pressure (right side of heart catheter), and arterial blood gases (radial artery catheter) were measured. Measurements of V˙/Q˙ matching, including alveolar dead space (Vdalv; Enghoff modification of the Bohr equation) and the alveolar-arterial Po2 difference (A-aDO2; alveolar gas equation), were also derived. The ventilation (V˙e)/CO2 elimination (V˙co2) slope was also calculated as the slope of the V˙e and V˙co2 relationship, which reflects ventilatory efficiency. RESULTS Ratings of perceived breathlessness increased (PLC: 3.43 ± 1.94 vs NTG: 4.03 ± 2.18; P = .009) despite a clear decrease in pulmonary capillary wedge pressure at 20 W (PLC: 19.7 ± 8.2 vs NTG: 15.9 ± 7.4 mm Hg; P < .001). Moreover, Vdalv (PLC: 0.28 ± 0.07 vs NTG: 0.31 ± 0.08 L/breath; P = .01), A-aDO2 (PLC: 19.6 ± 6.7 vs NTG: 21.1 ± 6.7; P = .04), and V˙e/V˙co2 slope (PLC: 37.6 ± 5.7 vs NTG: 40.2 ± 6.5; P < .001) all increased at 20 W after a decrease in pulmonary capillary wedge pressure. INTERPRETATION These findings have important clinical implications and indicate that lowering pulmonary capillary wedge pressure does not decrease dyspnea on exertion in patients with HFpEF; rather, lowering pulmonary capillary wedge pressure exacerbates dyspnea on exertion, increases V˙/Q˙ mismatch, and worsens ventilatory efficiency during exercise in these patients. This study provides compelling evidence that high pulmonary capillary wedge pressure is likely a secondary phenomenon rather than a primary cause of dyspnea on exertion in patients with HFpEF, and a new therapeutic paradigm is needed to improve symptoms of dyspnea on exertion in these patients.
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Affiliation(s)
- Bryce N Balmain
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Andrew R Tomlinson
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - James P MacNamara
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Linda S Hynan
- The O'Donnell School of Public Health and Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX
| | - Denis J Wakeham
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Satyam Sarma
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Tony G Babb
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.
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LaPenna KB, Li Z, Doiron JE, Sharp TE, Xia H, Moles K, Koul K, Wang JS, Polhemus DJ, Goodchild TT, Patel RB, Shah SJ, Lefer DJ. Combination Sodium Nitrite and Hydralazine Therapy Attenuates Heart Failure With Preserved Ejection Fraction Severity in a "2-Hit" Murine Model. J Am Heart Assoc 2023; 12:e028480. [PMID: 36752224 PMCID: PMC10111505 DOI: 10.1161/jaha.122.028480] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/04/2023] [Indexed: 02/09/2023]
Abstract
Background Recent studies have suggested that cardiac nitrosative stress mediated by pathological overproduction of nitric oxide (NO) via inducible NO synthase (iNOS) contributes to the pathogenesis of heart failure with preserved ejection fraction (HFpEF). Other studies have suggested that endothelial NO synthase (eNOS) dysfunction and attenuated NO bioavailability contribute to HFpEF morbidity and mortality. We sought to further investigate dysregulated NO signaling and to examine the effects of a NO-based dual therapy (sodium nitrite+hydralazine) following the onset of HFpEF using a "2-hit" murine model. Methods and Results Nine-week-old male C57BL/6 N mice (n=15 per group) were treated concurrently with high-fat diet and N(ω)-nitro-L-arginine methyl ester (L-NAME) (0.5 g/L per day) via drinking water for 10 weeks. At week 5, mice were randomized into either vehicle (normal saline) or combination treatment with sodium nitrite (75 mg/L in the drinking water) and hydralazine (2.0 mg/kg IP, BID). Cardiac structure and function were monitored with echocardiography and invasive hemodynamic measurements. Cardiac mitochondrial respiration, aortic vascular function, and exercise performance were also evaluated. Circulating and myocardial nitrite were measured to determine the bioavailability of NO. Circulating markers of oxidative or nitrosative stress as well as systemic inflammation were also determined. Severe HFpEF was evident by significantly elevated E/E', LVEDP, and Tau in mice treated with L-NAME and HFD, which was associated with impaired NO bioavailability, mitochondrial respiration, aortic vascular function, and exercise capacity. Treatment with sodium nitrite and hydralazine restored NO bioavailability, reduced oxidative and nitrosative stress, preserved endothelial function and mitochondrial respiration, limited the fibrotic response, and improved exercise capacity, ultimately attenuating the severity of "two-hit" HFpEF. Conclusions Our data demonstrate that nitrite, a well-established biomarker of NO bioavailability and a physiological source of NO, is significantly reduced in the heart and circulation in the "2-hit" mouse HFpEF model. Furthermore, sodium nitrite+hydralazine combined therapy significantly attenuated the severity of HFpEF in the "2-hit" cardiometabolic HFpEF. These data suggest that supplementing NO-based therapeutics with a potent antioxidant and vasodilator agent may result in synergistic benefits for the treatment of HFpEF.
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Affiliation(s)
- Kyle B. LaPenna
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
- Department of Pharmacology and Experimental TherapeuticsLouisiana State University Health Sciences CenterNew OrleansLA
| | - Zhen Li
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCA
| | - Jake E. Doiron
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
- Department of Pharmacology and Experimental TherapeuticsLouisiana State University Health Sciences CenterNew OrleansLA
| | - Thomas E. Sharp
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
- Department of Medicine, Section of CardiologyLouisiana State University Health Sciences CenterNew OrleansLA
| | - Huijing Xia
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
| | - Karl Moles
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
| | - Kashyap Koul
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
| | - John S. Wang
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
| | | | - Traci T. Goodchild
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCA
| | - Ravi B. Patel
- Division of Cardiology, Department of Medicine and Bluhm Cardiovascular InstituteNorthwestern University Feinberg School of MedicineChicagoIL
| | - Sanjiv J. Shah
- Division of Cardiology, Department of Medicine and Bluhm Cardiovascular InstituteNorthwestern University Feinberg School of MedicineChicagoIL
| | - David J. Lefer
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCA
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Cai Z, Wu C, Xu Y, Cai J, Zhao M, Zu L. The NO-cGMP-PKG Axis in HFpEF: From Pathological Mechanisms to Potential Therapies. Aging Dis 2023; 14:46-62. [PMID: 36818566 PMCID: PMC9937694 DOI: 10.14336/ad.2022.0523] [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: 03/07/2022] [Accepted: 05/23/2022] [Indexed: 11/18/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) accounts for almost half of all heart failure (HF) cases worldwide. Unfortunately, its incidence is expected to continue to rise, and effective therapy to improve clinical outcomes is lacking. Numerous efforts currently directed towards the pathophysiology of human HFpEF are uncovering signal transduction pathways and novel therapeutic targets. The nitric oxide-cyclic guanosine phosphate-protein kinase G (NO-cGMP-PKG) axis has been described as an important regulator of cardiac function. Suppression of the NO-cGMP-PKG signalling pathway is involved in the progression of HFpEF. Therefore, the NO-cGMP-PKG signalling pathway is a potential therapeutic target for HFpEF. In this review, we aim to explore the mechanism of NO-cGMP-PKG in the progression of HFpEF and to summarize potential therapeutic drugs that target this signalling pathway.
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Affiliation(s)
- Zhulan Cai
- Department of Cardiology, Peking University Third Hospital, Beijing 100191, China.,Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, China.
| | - Cencen Wu
- Department of Cardiology, Peking University Third Hospital, Beijing 100191, China.,Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, China.
| | - Yuan Xu
- Department of Cardiology, Peking University Third Hospital, Beijing 100191, China.,Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, China.
| | - Jiageng Cai
- Department of Cardiology, Peking University Third Hospital, Beijing 100191, China.,Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, China.
| | - Menglin Zhao
- Department of Cardiology, Peking University Third Hospital, Beijing 100191, China.,Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, China.
| | - Lingyun Zu
- Department of Cardiology, Peking University Third Hospital, Beijing 100191, China.,Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, China.,Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, China.,Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing 100191, China,Correspondence should be addressed to: Dr. Lingyun Zu, Department of Cardiology, Peking University Third Hospital, Beijing 100191, China. .
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Namba T, Masaki N, Hitomi Y, Ishinoda Y, Iwashita M, Yumita Y, Kagami K, Yasuda R, Ikegami Y, Toya T, Nagatomo Y, Takase B, Soejima K, Adachi T. Association of serum nitric oxide metabolite level with mortality in patients undergoing coronary angiography. J Cardiol 2022; 80:578-584. [PMID: 35987881 DOI: 10.1016/j.jjcc.2022.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/14/2022] [Accepted: 07/20/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Nitric oxide (NO) is a relevant molecule for vascular homeostasis. The level of serum NO metabolites (NOx), which consist of nitrite and nitrate, has been investigated as an alternative biomarker of NO production, but its clinical value has not yet been determined. METHODS AND RESULTS 143 patients (66 ± 12 years old) were followed up after coronary catheterization. During a median (inter-quartile range) observation period of 6.13 (3.32-9.21) years, there were 20 (14 %) all-cause deaths, including 11 (8 %) cardiovascular deaths, 17 (12 %) major adverse cardiovascular events, and 17 (12 %) hospital admissions for heart failure. Median NOx level was 34.5 μmol/L (23.9-54.3). NOx was a risk factor for all-cause death [hazard ratio (HR) by unit increase, 1.010, 95 % confidence interval (CI) 1.001-1.018; p = 0.021] and heart failure (HR 1.010, CI 1.001-1.019; p = 0.029). Even after adjustment for age, sex, coronary risk factors, C-reactive protein, log-transformed brain natriuretic peptide, estimated glomerular filtration rate, and nitrate treatment, NOx was a risk factor for all-cause death (HR 1.015, CI 1.004-1.027; p = 0.008) and admission with heart failure (HR 1.018, CI 1.005-1.018, p = 0.007). CONCLUSIONS An increase in serum NOx level does not herald a benign clinical course but is an independent predictor of high risk of any-cause mortality and heart failure.
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Affiliation(s)
- Takayuki Namba
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan; Department of Cardiology, Kyorin University School of Medicine, Mitaka, Japan
| | - Nobuyuki Masaki
- Department of Intensive Care Medicine, National Defense Medical College, Tokorozawa, Japan.
| | - Yasuhiro Hitomi
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
| | - Yuki Ishinoda
- Department of Endocrinology, National Defense Medical College, Tokorozawa, Japan
| | - Midori Iwashita
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
| | - Yusuke Yumita
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
| | - Kazuki Kagami
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
| | - Risako Yasuda
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
| | - Yukinori Ikegami
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
| | - Takumi Toya
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan; Department of Intensive Care Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
| | - Bonpei Takase
- Department of Intensive Care Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Kyoko Soejima
- Department of Cardiology, Kyorin University School of Medicine, Mitaka, Japan
| | - Takeshi Adachi
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
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Prevalence, risk factors, and survival associated with pulmonary hypertension and heart failure among patients with underlying coronary artery disease: a national prospective, multicenter registry study in China. Chin Med J (Engl) 2022; 135:1837-1845. [PMID: 36195993 PMCID: PMC9521769 DOI: 10.1097/cm9.0000000000002112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Coronary artery disease (CAD) is the commonest cause of heart failure (HF), whereas pulmonary hypertension (PH) has not been established or reported in this patient population. Therefore, we assessed the prevalence, risk factors, and survival in CAD-associated HF (CAD-HF) complicated with PH. METHODS Symptomatic CAD-HF patients were continuously enrolled in this prospective, multicenter registry study. Echocardiography, coronary arteriography, left and right heart catheterization (RHC), and other baseline clinical data were recorded. Patients were followed up and their survival was recorded. RESULTS One hundred and eighty-two CAD-HF patients were enrolled, including 142 with HF with a preserved ejection fraction (heart failure with preserved ejection fraction [HFpEF]; left ventricular ejection fraction [LVEF] ≥50%) and 40 with a reduced ejection fraction (heart failure with reduced ejection fraction [HFrEF]; LVEF < 50%). PH was diagnosed with RHC in 77.5% of patients. Patients with PH showed worse hemodynamic parameters and higher mortality. HFrEF-PH patients had worse survival than HFpEF-PH patients. CAD-HF patients with an enlarged left ventricular end-diastolic diameter and reduced hemoglobin were at higher risk of PH. Nitrate treatment reduced the risk of PH. Elevated creatinine and mean pulmonary arterial pressure (mPAP), diastolic pressure gradient (DPG) ≥7 mmHg, and previous myocardial infarction (MI) entailed a higher risk of mortality in CAD-HF patients with PH. CONCLUSIONS PH is common in CAD-HF and worsens the hemodynamics and survival in these patients. Left ventricle enlargement and anemia increase the risk of PH in CAD-HF. Patients may benefit from nitrate medications. Renal impairment, elevated mPAP, DPG ≥7 mmHg, and previous MI are strong predictors of mortality in CAD-HF-PH patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT02164526.
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Systems Pharmacology-Based Strategy to Investigate Pharmacological Mechanisms of Total Flavonoids in Dracocephalum moldavica on Chronic Heart Failure. Int J Mol Sci 2022; 23:ijms23158409. [PMID: 35955548 PMCID: PMC9368860 DOI: 10.3390/ijms23158409] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 11/17/2022] Open
Abstract
Heart failure (HF) is a clinical syndrome of cardiac insufficiency caused by abnormalities in cardiac structure and function that arise for various reasons, and it is the final stage of most cardiovascular diseases’ progression. Total flavonoid extract from Dracocephalum moldavica L. (TFDM) has many pharmacological and biological roles, such as cardioprotective, neuroprotective, anti-atherogenic, antihypertensive, anti-diabetic, anti-inflammatory, antioxidant, etc. However, its effect on HF and its molecular mechanism are still unclear. In this study, we used systems pharmacology and an animal model of HF to investigate the cardioprotective effect of TFDM and its molecular mechanism. Eleven compounds in TFDM were obtained from the literature, and 114 overlapping genes related to TFDM and HF were collected from several databases. A PPI network and C-T network were established, and GO enrichment analysis and KEGG pathway analysis were performed. The top targets from the PPI network and C-T network were validated using molecular docking. The pharmacological activity was investigated in an HFpEF (heart failure with preserved ejection fraction) mouse model. This study shows that TFDM has a protective effect on HFpEF, and its protective mechanism may be related to the regulation of proinflammatory cytokines, apoptosis-related genes, fibrosis-related genes, etc. Collectively, this study offers new insights for researchers to understand the protective effect and mechanism of TFDM against HFpEF using a network pharmacology method and a murine model of HFpEF, which suggest that TFDM is a promising therapy for HFpEF in the clinic.
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The Cardiomyocyte in Heart Failure with Preserved Ejection Fraction—Victim of Its Environment? Cells 2022; 11:cells11050867. [PMID: 35269489 PMCID: PMC8909081 DOI: 10.3390/cells11050867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/01/2022] [Indexed: 12/07/2022] Open
Abstract
Heart failure (HF) with preserved left ventricular ejection fraction (HFpEF) is becoming the predominant form of HF. However, medical therapy that improves cardiovascular outcome in HF patients with almost normal and normal systolic left ventricular function, but diastolic dysfunction is missing. The cause of this unmet need is incomplete understanding of HFpEF pathophysiology, the heterogeneity of the patient population, and poor matching of therapeutic mechanisms and primary pathophysiological processes. Recently, animal models improved understanding of the pathophysiological role of highly prevalent and often concomitantly presenting comorbidity in HFpEF patients. Evidence from these animal models provide first insight into cellular pathophysiology not considered so far in HFpEF disease, promising that improved understanding may provide new therapeutical targets. This review merges observation from animal models and human HFpEF disease with the intention to converge cardiomyocytes pathophysiological aspects and clinical knowledge.
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11
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VDAC2 as a novel target for heart failure: Ca2+ at the sarcomere, mitochondria and SR. Cell Calcium 2022; 104:102586. [DOI: 10.1016/j.ceca.2022.102586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/25/2022] [Accepted: 03/26/2022] [Indexed: 11/22/2022]
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12
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Kobak KA, Zarzycka W, Chiao YA. Age and Sex Differences in Heart Failure With Preserved Ejection Fraction. FRONTIERS IN AGING 2022; 3:811436. [PMID: 35821846 PMCID: PMC9261310 DOI: 10.3389/fragi.2022.811436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/13/2022] [Indexed: 11/29/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a multi-organ disorder that represents about 50% of total heart failure (HF) cases and is the most common form of HF in the elderly. Because of its increasing prevalence caused by the aging population, high mortality and morbidity, and very limited therapeutic options, HFpEF is considered as one of the greatest unmet medical needs in cardiovascular medicine. Despite its complex pathophysiology, numerous preclinical models have been established in rodents and in large animals to study HFpEF pathophysiology. Although age and sex differences are well described in HFpEF population, there are knowledge gaps in sex- and age-specific differences in established preclinical models. In this review, we summarize various strategies that have been used to develop HFpEF models and discuss the knowledge gaps in sex and age differences in HFpEF.
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13
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de Alencar AKN, Wang H, de Oliveira GMM, Sun X, Zapata-Sudo G, Groban L. Crossroads between Estrogen Loss, Obesity, and Heart Failure with Preserved Ejection Fraction. Arq Bras Cardiol 2021; 117:1191-1201. [PMID: 34644788 PMCID: PMC8757160 DOI: 10.36660/abc.20200855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 12/16/2020] [Accepted: 01/27/2021] [Indexed: 11/24/2022] Open
Abstract
The prevalence of obesity and heart failure with preserved ejection fraction (HFpEF) increases significantly in postmenopausal women. Although obesity is a risk factor for left ventricular diastolic dysfunction (LVDD), the mechanisms that link the cessation of ovarian hormone production, and particularly estrogens, to the development of obesity, LVDD, and HFpEF in aging females are unclear. Clinical, and epidemiologic studies show that postmenopausal women with abdominal obesity (defined by waist circumference) are at greater risk for developing HFpEF than men or women without abdominal obesity. The study presents a review of clinical data that support a mechanistic link between estrogen loss plus obesity and left ventricular remodeling with LVDD. It also seeks to discuss potential cell and molecular mechanisms for estrogen-mediated protection against adverse adipocyte cell types, tissue depots, function, and metabolism that may contribute to LVDD and HFpEF.
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Affiliation(s)
| | - Hao Wang
- Wake Forest School of MedicineDepartments of AnesthesiologyWinston-SalemNorth CarolinaEstados Unidos da AméricaWake Forest School of Medicine - Departments of Anesthesiology, Winston-Salem, North Carolina - Estados Unidos da América
- Wake Forest School of MedicineWinston-SalemNorth CarolinaEstados Unidos da AméricaWake Forest School of Medicine - Internal Medicine-Section of Molecular Medicine, Winston-Salem, North Carolina - Estados Unidos da América
| | - Gláucia Maria Moraes de Oliveira
- Universidade Federal do Rio de JaneiroDepartamento de Clínica MédicaFaculdade de MedicinaRio de JaneiroRJBrasilUniversidade Federal do Rio de Janeiro - Departamento de Clínica Médica, Faculdade de Medicina, Rio de Janeiro, RJ - Brasil
| | - Xuming Sun
- Wake Forest School of MedicineDepartments of AnesthesiologyWinston-SalemNorth CarolinaEstados Unidos da AméricaWake Forest School of Medicine - Departments of Anesthesiology, Winston-Salem, North Carolina - Estados Unidos da América
| | - Gisele Zapata-Sudo
- Universidade Federal do Rio de JaneiroInstituto de Ciências BiomédicasRio de JaneiroRJBrasilUniversidade Federal do Rio de Janeiro - Instituto de Ciências Biomédicas, Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de JaneiroInstituto de Cardiologia Edson SaadFaculdade de MedicinaRio de JaneiroRJBrasilUniversidade Federal do Rio de Janeiro - Instituto de Cardiologia Edson Saad, Faculdade de Medicina, Rio de Janeiro, RJ - Brasil
| | - Leanne Groban
- Wake Forest School of MedicineDepartments of AnesthesiologyWinston-SalemNorth CarolinaEstados Unidos da AméricaWake Forest School of Medicine - Departments of Anesthesiology, Winston-Salem, North Carolina - Estados Unidos da América
- Wake Forest School of MedicineWinston-SalemNorth CarolinaEstados Unidos da AméricaWake Forest School of Medicine - Internal Medicine-Section of Molecular Medicine, Winston-Salem, North Carolina - Estados Unidos da América
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14
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Otto M, Brabenec L, Müller M, Kintrup S, Hellenthal KEM, Holtmeier R, Steinbuch SC, Karsten OS, Pryvalov H, Rossaint J, Gross ER, Wagner NM. Development of heart failure with preserved ejection fraction in type 2 diabetic mice is ameliorated by preserving vascular function. Life Sci 2021; 284:119925. [PMID: 34480933 PMCID: PMC8484044 DOI: 10.1016/j.lfs.2021.119925] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/13/2021] [Accepted: 08/21/2021] [Indexed: 11/26/2022]
Abstract
AIMS Heart failure with preserved ejection fraction (HFpEF) is associated with endothelial dysfunction and is frequent in people with type 2 diabetes mellitus. In diabetic patients, increased levels of the eicosanoid 12-hydroxyeicosatetraenoic acid (12-HETE) are linked to vascular dysfunction. Here, we aimed to identify the importance of 12-HETE in type 2 diabetic patients exhibiting diastolic dysfunction, and mice exhibiting HFpEF and whether targeting 12-HETE is a means to ameliorate HFpEF progression by improving vascular function in diabetes. MATERIAL AND METHODS Subjects with diagnosed type 2 diabetes mellitus and reported diastolic dysfunction or healthy controls were recruited and 12(S)-HETE levels determined by ELISA. 12(S)-HETE levels were determined in type 2 diabetic, leptin receptor deficient mice (LepRdb/db) and HFpEF verified by echocardiography. Mitochondrial function, endothelial function and capillary density were assessed using Seahorse technique, pressure myography and immunohistochemistry in LepRdb/db or non-diabetic littermate controls. 12/15Lo generation was inhibited using ML351 and 12(S)-HETE action by using the V1-cal peptide. KEY FINDINGS Endothelium-dependent vasodilation and mitochondrial functional capacity both improved in response to either application of ML351 or the V1-cal peptide. Correlating to improved vascular function, mice treated with either pharmacological agent exhibited improved diastolic filling and left ventricular relaxation that correlated with increased myocardial capillary density. SIGNIFICANCE Our results suggest that 12-HETE may serve as a biomarker indicating endothelial dysfunction and the resulting cardiovascular consequences such as HFpEF in type 2 diabetic patients. Antagonizing 12-HETE is a potent means to causally control HFpEF development and progression in type 2 diabetes by preserving vascular function.
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Affiliation(s)
- Mandy Otto
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Laura Brabenec
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Melanie Müller
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Sebastian Kintrup
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Katharina E M Hellenthal
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Richard Holtmeier
- Institute of Clinical Radiology, University Hospital Muenster, Muenster, Germany
| | - Sophie Charlotte Steinbuch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Ole Sönken Karsten
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Heorhii Pryvalov
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Jan Rossaint
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Eric R Gross
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Nana-Maria Wagner
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany.
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15
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Arginine metabolism and nitric oxide turnover in the ZSF1 animal model for heart failure with preserved ejection fraction. Sci Rep 2021; 11:20684. [PMID: 34667218 PMCID: PMC8526609 DOI: 10.1038/s41598-021-00216-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/07/2021] [Indexed: 12/21/2022] Open
Abstract
Endothelial dysfunction and altered nitric oxide (NO) metabolism are considered causal factors in heart failure with preserved ejection fraction (HFpEF). NO synthase activity depends on the availability of arginine and its derivatives. Thus, we analyzed arginine, associated metabolites, arginine-metabolizing enzymes and NO turnover in 20-week-old female healthy lean (L-ZSF1) and obese ZSF1 rats (O-ZSF1) with HFpEF. Serum, urine and lysates of liver, kidney and heart were analyzed. There were significantly lower lysine (− 28%), arginine (− 31%), homoarginine (− 72%) and nitrite (− 32%) levels in serum of O-ZSF1 rats. Ornithine (+ 60%) and citrulline (+ 20%) levels were higher. Similar results were found in the heart. Expression of arginine consuming enzymes in liver and kidney was unchanged. Instead, we observed a 5.8-fold higher arginase 1 expression, presumably of granulocyte origin, in serum and > fourfold increased cardiac macrophage invasion in O-ZSF1. We conclude that inflammatory cells in blood and heart consume arginine and probably homoarginine via arginase 1 and inducible NO synthase and release ornithine and citrulline. In combination with evidence for decreased NO turnover in O-ZSF1 rats, we assume lower arginine bioavailability to endothelial NO synthase.
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16
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Gee LC, Massimo G, Lau C, Primus C, Fernandes D, Chen J, Rathod KS, Hamers AJP, Filomena F, Nuredini G, Ibrahim AS, Khambata RS, Gupta AK, Moon JC, Kapil V, Ahluwalia A. Inorganic nitrate attenuates cardiac dysfunction: role for xanthine oxidoreductase and nitric oxide. Br J Pharmacol 2021; 179:4757-4777. [PMID: 34309015 DOI: 10.1111/bph.15636] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 07/01/2021] [Accepted: 07/03/2021] [Indexed: 11/28/2022] Open
Abstract
Nitric oxide (NO) is a vasodilator and independent modulator of cardiac remodelling. Commonly, in cardiac disease (e.g. heart failure) endothelial dysfunction (synonymous with NO-deficiency) has been implicated in increased blood pressure (BP), cardiac hypertrophy and fibrosis. Currently no effective therapies replacing NO have succeeded in the clinic. Inorganic nitrate (NO3 - ), through chemical reduction to nitrite and then NO, exerts potent BP-lowering but whether it might be useful in treating undesirable cardiac remodelling is unknown. In a nested age- and sex-matched case-control study of hypertensive patients +/- left ventricular hypertrophy (NCT03088514) we show that lower plasma nitrite concentration and vascular dysfunction accompany cardiac hypertrophy and fibrosis in patients. In mouse models of cardiac remodelling, we also show that restoration of circulating nitrite levels using dietary nitrate improves endothelial dysfunction through targeting of xanthine oxidoreductase (XOR)-driven H2 O2 and superoxide, and reduces cardiac fibrosis through NO-mediated block of SMAD-phosphorylation leading to improvements in cardiac structure and function. We show that via these mechanisms dietary nitrate offers easily translatable therapeutic options for treatment of cardiac dysfunction.
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Affiliation(s)
- Lorna C Gee
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Gianmichele Massimo
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Clement Lau
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Christopher Primus
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Daniel Fernandes
- Departamento de Farmacologia, Federal University of Santa Catarina, Florianópolis, Santa Catarina,, Brazil
| | - Jianmin Chen
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Krishnaraj S Rathod
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Alexander Jozua Pedro Hamers
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Federica Filomena
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Gani Nuredini
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Abdiwahab Shidane Ibrahim
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Rayomand S Khambata
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Ajay K Gupta
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - James C Moon
- UCL Institute of Cardiovascular Science, University College London, London, UK
| | - Vikas Kapil
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Amrita Ahluwalia
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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17
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Current Status of Pharmacologic and Nonpharmacologic Therapy in Heart Failure with Preserved Ejection Fraction. Heart Fail Clin 2021; 17:463-482. [PMID: 34051977 DOI: 10.1016/j.hfc.2021.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a significantly symptomatic disease and has a poor prognosis similar to that of heart failure with reduced ejection fraction (HFrEF). Contrary to HFrEF, HFpEF is difficult to diagnose, and the recommended diagnostic algorithm of HFpEF is complicated. Several therapies for HFpEF have failed to reduce mortality or morbidity. HFpEF is thought to be a complex and heterogeneous systemic disorder that has various phenotypes and multiple comorbidities. Therefore, therapeutic strategies of HFpEF need to change depending on the phenotype of the patient. This review highlights the pharmacologic and nonpharmacologic treatment of HFpEF.
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18
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Mishra S, Kass DA. Cellular and molecular pathobiology of heart failure with preserved ejection fraction. Nat Rev Cardiol 2021; 18:400-423. [PMID: 33432192 PMCID: PMC8574228 DOI: 10.1038/s41569-020-00480-6] [Citation(s) in RCA: 181] [Impact Index Per Article: 60.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 01/30/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) affects half of all patients with heart failure worldwide, is increasing in prevalence, confers substantial morbidity and mortality, and has very few effective treatments. HFpEF is arguably the greatest unmet medical need in cardiovascular disease. Although HFpEF was initially considered to be a haemodynamic disorder characterized by hypertension, cardiac hypertrophy and diastolic dysfunction, the pandemics of obesity and diabetes mellitus have modified the HFpEF syndrome, which is now recognized to be a multisystem disorder involving the heart, lungs, kidneys, skeletal muscle, adipose tissue, vascular system, and immune and inflammatory signalling. This multiorgan involvement makes HFpEF difficult to model in experimental animals because the condition is not simply cardiac hypertrophy and hypertension with abnormal myocardial relaxation. However, new animal models involving both haemodynamic and metabolic disease, and increasing efforts to examine human pathophysiology, are revealing new signalling pathways and potential therapeutic targets. In this Review, we discuss the cellular and molecular pathobiology of HFpEF, with the major focus being on mechanisms relevant to the heart, because most research has focused on this organ. We also highlight the involvement of other important organ systems, including the lungs, kidneys and skeletal muscle, efforts to characterize patients with the use of systemic biomarkers, and ongoing therapeutic efforts. Our objective is to provide a roadmap of the signalling pathways and mechanisms of HFpEF that are being characterized and which might lead to more patient-specific therapies and improved clinical outcomes.
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Affiliation(s)
- Sumita Mishra
- Department of Medicine, Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David A. Kass
- Department of Medicine, Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pharmacology and Molecular Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,
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19
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Ferguson SK, Woessner MN, Holmes MJ, Belbis MD, Carlström M, Weitzberg E, Allen JD, Hirai DM. Effects of inorganic nitrate supplementation on cardiovascular function and exercise tolerance in heart failure. J Appl Physiol (1985) 2021; 130:914-922. [PMID: 33475460 PMCID: PMC8424551 DOI: 10.1152/japplphysiol.00780.2020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 01/11/2023] Open
Abstract
Heart failure (HF) results in a myriad of central and peripheral abnormalities that impair the ability to sustain skeletal muscle contractions and, therefore, limit tolerance to exercise. Chief among these abnormalities is the lowered maximal oxygen uptake, which is brought about by reduced cardiac output and exacerbated by O2 delivery-utilization mismatch within the active skeletal muscle. Impaired nitric oxide (NO) bioavailability is considered to play a vital role in the vascular dysfunction of both reduced and preserved ejection fraction HF (HFrEF and HFpEF, respectively), leading to the pursuit of therapies aimed at restoring NO levels in these patient populations. Considering the complementary role of the nitrate-nitrite-NO pathway in the regulation of enzymatic NO signaling, this review explores the potential utility of inorganic nitrate interventions to increase NO bioavailability in the HFrEF and HFpEF patient population. Although many preclinical investigations have suggested that enhanced reduction of nitrite to NO in low Po2 and pH environments may make a nitrate-based therapy especially efficacious in patients with HF, inconsistent results have been found thus far in clinical settings. This brief review provides a summary of the effectiveness (or lack thereof) of inorganic nitrate interventions on exercise tolerance in patients with HFrEF and HFpEF. Focus is also given to practical considerations and current gaps in the literature to facilitate the development of effective nitrate-based interventions to improve exercise tolerance in patients with HF.
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Affiliation(s)
- Scott K Ferguson
- Department of Kinesiology and Exercise Science, College of Natural and Health Sciences, University of Hawaii at Hilo, Hilo, Hawaii
| | - Mary N Woessner
- Institute for Health and Sport, Victoria University, Melbourne, Australia
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Michael J Holmes
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana
| | - Michael D Belbis
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana
| | - Mattias Carlström
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Eddie Weitzberg
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Jason D Allen
- Department of Kinesiology & Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
| | - Daniel M Hirai
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana
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20
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Miranda-Silva D, Lima T, Rodrigues P, Leite-Moreira A, Falcão-Pires I. Mechanisms underlying the pathophysiology of heart failure with preserved ejection fraction: the tip of the iceberg. Heart Fail Rev 2021; 26:453-478. [PMID: 33411091 DOI: 10.1007/s10741-020-10042-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 12/18/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a multifaceted syndrome with a complex aetiology often associated with several comorbidities, such as left ventricle pressure overload, diabetes mellitus, obesity, and kidney disease. Its pathophysiology remains obscure mainly due to the complex phenotype induced by all these associated comorbidities and to the scarcity of animal models that adequately mimic HFpEF. Increased oxidative stress, inflammation, and endothelial dysfunction are currently accepted as key players in HFpEF pathophysiology. However, we have just started to unveil HFpEF complexity and the role of calcium handling, energetic metabolism, and mitochondrial function remain to clarify. Indeed, the enlightenment of such cellular and molecular mechanisms represents an opportunity to develop novel therapeutic approaches and thus to improve HFpEF treatment options. In the last decades, the number of research groups dedicated to studying HFpEF has increased, denoting the importance and the magnitude achieved by this syndrome. In the current technological and web world, the amount of information is overwhelming, driving us not only to compile the most relevant information about the theme but also to explore beyond the tip of the iceberg. Thus, this review aims to encompass the most recent knowledge related to HFpEF or HFpEF-associated comorbidities, focusing mainly on myocardial metabolism, oxidative stress, and energetic pathways.
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Affiliation(s)
- Daniela Miranda-Silva
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Tânia Lima
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Patrícia Rodrigues
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Adelino Leite-Moreira
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Inês Falcão-Pires
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
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21
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Ramick MG, Kirkman DL, Stock JM, Muth BJ, Farquhar WB, Chirinos JA, Doulias PT, Ischiropoulos H, Edwards DG. The effect of dietary nitrate on exercise capacity in chronic kidney disease: a randomized controlled pilot study. Nitric Oxide 2021; 106:17-23. [PMID: 33080411 PMCID: PMC10026360 DOI: 10.1016/j.niox.2020.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/12/2020] [Accepted: 10/15/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chronic Kidney Disease (CKD) patients exhibit a reduced exercise capacity that impacts quality of life. Dietary nitrate supplementation has been shown to have favorable effects on exercise capacity in disease populations by reducing the oxygen cost of exercise. This study investigated whether dietary nitrates would acutely improve exercise capacity in CKD patients. METHODS AND RESULTS In this randomized, double-blinded crossover study, 12 Stage 3-4 CKD patients (Mean ± SEM: Age, 60 ± 5yrs; eGFR, 50.3 ± 4.6 ml/min/1.73 m2) received an acute dose of 12.6 mmol of dietary nitrate in the form of concentrated beetroot juice (BRJ) and a nitrate depleted placebo (PLA). Skeletal muscle mitochondrial oxidative function was assessed using near-infrared spectroscopy. Cardiopulmonary exercise testing was performed on a cycle ergometer, with intensity increased by 25 W every 3 min until volitional fatigue. Plasma nitric oxide (NO) metabolites (NOm; nitrate, nitrite, low molecular weight S-nitrosothiols, and metal bound NO) were determined by gas-phase chemiluminescence. Plasma NOm values were significantly increased following BRJ (BRJ vs. PLA: 1074.4 ± 120.4 μM vs. 28.4 ± 6.6 μM, p < 0.001). Total work performed (44.4 ± 10.6 vs 39.6 ± 9.9 kJ, p = 0.03) and total exercise time (674 ± 85 vs 627 ± 86s, p = 0.04) were significantly greater following BRJ. Oxygen consumption at the ventilatory threshold was also improved by BRJ (0.90 ± 0.08 vs. 0.74 ± 0.06 L/min, p = 0.04). These changes occurred in the absence of improved skeletal muscle mitochondrial oxidative capacity (p = 0.52) and VO2peak (p = 0.35). CONCLUSIONS Our findings demonstrate that inorganic nitrate can acutely improve exercise capacity in CKD patients. The effects of chronic nitrate supplementation on CKD related exercise intolerance should be investigated in future studies.
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Affiliation(s)
- Meghan G Ramick
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA; Department of Kinesiology, West Chester University, West Chester, PA, USA
| | - Danielle L Kirkman
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA; Department of Kinesiology and Health Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Joseph M Stock
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
| | - Bryce J Muth
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA; School of Health Sciences, Stockton University, Stockton, NJ, USA
| | - William B Farquhar
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
| | - Julio A Chirinos
- Division of Cardiovascular Medicine. Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paschalis-Thomas Doulias
- Laboratory of Biochemistry, Department of Chemistry, School of Sciences, University of Ioannina, Ioannina, 45110, Greece; Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, USA
| | - Harry Ischiropoulos
- Laboratory of Biochemistry, Department of Chemistry, School of Sciences, University of Ioannina, Ioannina, 45110, Greece; Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, USA
| | - David G Edwards
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA.
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22
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Kim MN, Park SM. Heart failure with preserved ejection fraction: insights from recent clinical researches. Korean J Intern Med 2020; 35:514-534. [PMID: 32392659 PMCID: PMC7214356 DOI: 10.3904/kjim.2020.104] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 04/23/2020] [Indexed: 02/07/2023] Open
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) accounts for nearly half of the cases of HF and its incidence might be increasing with the aging society. Patients with HFpEF present with significant symptoms, including exercise intolerance, impaired quality of life, and have a poor prognosis as well as frequent hospitalization and increased mortality compared with HF with reduced ejection fraction. The concept of HFpEF is still evolving and may be a virtual complex rather than a real systemic disorder. Thus, beyond solely targeting cardiac abnormalities management strategies need to be extended, such as left ventricular diastolic dysfunction. In this review, we examine new diagnostic algorithms, pathophysiology, current management status, and ongoing trials based on heterogeneous pathophysiology and etiology in HFpEF.
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Affiliation(s)
- Mi-Na Kim
- Division of Cardiology, Korea University Anam Hospital, Seoul, Korea
| | - Seong-Mi Park
- Division of Cardiology, Korea University Anam Hospital, Seoul, Korea
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23
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Van Linthout S, Rimoldi O, Tschöpe C, Camici PG. Coronary microvascular dysfunction in heart failure with preserved ejection fraction - adding new pieces to the jigsaw puzzle. Eur J Heart Fail 2020; 22:442-444. [PMID: 31912570 DOI: 10.1002/ejhf.1720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 11/26/2019] [Indexed: 01/09/2023] Open
Affiliation(s)
- Sophie Van Linthout
- Charité - Universitätsmedizin Berlin, BCRT - Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Ornella Rimoldi
- Vita Salute University and San Raffaele Hospital, Milan, Italy.,CNR IBFM Istituto Bioimmagini e Fisiologia Molecolare, Segrate (MI), Italy
| | - Carsten Tschöpe
- Charité - Universitätsmedizin Berlin, BCRT - Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany.,Department of Cardiology, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
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24
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Kumar AA, Kelly DP, Chirinos JA. Mitochondrial Dysfunction in Heart Failure With Preserved Ejection Fraction. Circulation 2019; 139:1435-1450. [PMID: 30856000 DOI: 10.1161/circulationaha.118.036259] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a complex syndrome with an increasingly recognized heterogeneity in pathophysiology. Exercise intolerance is the hallmark of HFpEF and appears to be caused by both cardiac and peripheral abnormalities in the arterial tree and skeletal muscle. Mitochondrial abnormalities can significantly contribute to impaired oxygen utilization and the resulting exercise intolerance in HFpEF. We review key aspects of the complex biology of this organelle, the clinical relevance of mitochondrial function, the methods that are currently available to assess mitochondrial function in humans, and the evidence supporting a role for mitochondrial dysfunction in the pathophysiology of HFpEF. We also discuss the role of mitochondrial function as a therapeutic target, some key considerations for the design of early-phase clinical trials using agents that specifically target mitochondrial function to improve symptoms in patients with HFpEF, and ongoing trials with mitochondrial agents in HFpEF.
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Affiliation(s)
- Anupam A Kumar
- From the University of Pennsylvania Perelman School of Medicine, Philadelphia (A.K., D.P.K., J.C.)
| | - Daniel P Kelly
- From the University of Pennsylvania Perelman School of Medicine, Philadelphia (A.K., D.P.K., J.C.)
| | - Julio A Chirinos
- From the University of Pennsylvania Perelman School of Medicine, Philadelphia (A.K., D.P.K., J.C.).,the Hospital of the University of Pennsylvania, Philadelphia (J.C.)
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25
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Oh A, Okazaki R, Sam F, Valero-Muñoz M. Heart Failure With Preserved Ejection Fraction and Adipose Tissue: A Story of Two Tales. Front Cardiovasc Med 2019; 6:110. [PMID: 31428620 PMCID: PMC6687767 DOI: 10.3389/fcvm.2019.00110] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/22/2019] [Indexed: 12/11/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is characterized by signs and symptoms of heart failure in the presence of a normal left ventricular ejection fraction. Although it accounts for up to 50% of all clinical presentations of heart failure, there are no evidence-based therapies for HFpEF to reduce morbidity and mortality. Additionally there is a lack of mechanistic understanding about the pathogenesis of HFpEF. HFpEF is associated with many comorbidities (such as obesity, hypertension, type 2 diabetes, atrial fibrillation, etc.) and is coupled with both cardiac and extra-cardiac abnormalities. Large outcome trials and registries reveal that being obese is a major risk factor for HFpEF. There is increasing focus on investigating the link between obesity and HFpEF, and the role that the adipose tissue and the heart, and the circulating milieu play in development and pathogenesis of HFpEF. This review discusses features of the obese-HFpEF phenotype and highlights proposed mechanisms implicated in the inter-tissue communication between adipose tissue and the heart in obesity-associated HFpEF.
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Affiliation(s)
- Albin Oh
- Evans Department of Medicine, Boston Medical Center, Boston, MA, United States
| | - Ross Okazaki
- Boston University School of Medicine, Boston, MA, United States
| | - Flora Sam
- Evans Department of Medicine, Boston Medical Center, Boston, MA, United States.,Boston University School of Medicine, Boston, MA, United States.,Section of Cardiovascular Medicine, Boston Medical Center, Boston, MA, United States.,Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, United States
| | - Maria Valero-Muñoz
- Boston University School of Medicine, Boston, MA, United States.,Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, United States
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26
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Nakamura T, Zhu G, Ranek MJ, Kokkonen-Simon K, Zhang M, Kim GE, Tsujita K, Kass DA. Prevention of PKG-1α Oxidation Suppresses Antihypertrophic/Antifibrotic Effects From PDE5 Inhibition but not sGC Stimulation. Circ Heart Fail 2019; 11:e004740. [PMID: 29545395 DOI: 10.1161/circheartfailure.117.004740] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 01/17/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Stimulation of sGC (soluble guanylate cyclase) or inhibition of PDE5 (phosphodiesterase type 5) activates PKG (protein kinase G)-1α to counteract cardiac hypertrophy and failure. PKG1α acts within localized intracellular domains; however, its oxidation at cysteine 42, linking homomonomers, alters this localization, impairing suppression of pathological cardiac stress. Because PDE5 and sGC reside in separate microdomains, we speculated that PKG1α oxidation might also differentially influence the effects from their pharmacological modulation. METHODS AND RESULTS Knock-in mice expressing a redox-dead PKG1α (PKG1αC42S) or littermate controls (PKG1αWT) were subjected to transaortic constriction to induce pressure overload and treated with a PDE5 inhibitor (sildenafil), sGC activator (BAY602770 [BAY]), or vehicle. In PKG1αWT controls, sildenafil and BAY similarly enhanced PKG activity and reduced pathological hypertrophy/fibrosis and cardiac dysfunction after transaortic constriction. However, sildenafil failed to protect the heart in PKG1αC42S, unlike BAY, which activated PKG and thereby facilitated protective effects. This corresponded with minimal PDE5 activation in PKG1αC42S exposed to transaortic constriction versus higher activity in controls and little colocalization of PDE5 with PKG1αC42S (versus colocalization with PKG1αWT) in stressed myocytes. CONCLUSIONS In the stressed heart and myocytes, PKG1α C42-disulfide formation contributes to PDE5 activation. This augments the pathological role of PDE5 and so in turn enhances the therapeutic impact from its inhibition. PKG1α oxidation does not change the benefits from sGC activation. This finding favors the use of sGC activators regardless of PKG1α oxidation and may help guide precision therapy leveraging the cyclic GMP/PKG pathway to treat heart disease.
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Affiliation(s)
- Taishi Nakamura
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (T.N., G.Z., M.J.R., K.K.-S., M.Z., G.E.K., D.A.K.); and Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (T.N., K.T.)
| | - Guangshuo Zhu
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (T.N., G.Z., M.J.R., K.K.-S., M.Z., G.E.K., D.A.K.); and Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (T.N., K.T.)
| | - Mark J Ranek
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (T.N., G.Z., M.J.R., K.K.-S., M.Z., G.E.K., D.A.K.); and Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (T.N., K.T.)
| | - Kristen Kokkonen-Simon
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (T.N., G.Z., M.J.R., K.K.-S., M.Z., G.E.K., D.A.K.); and Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (T.N., K.T.)
| | - Manling Zhang
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (T.N., G.Z., M.J.R., K.K.-S., M.Z., G.E.K., D.A.K.); and Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (T.N., K.T.)
| | - Grace E Kim
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (T.N., G.Z., M.J.R., K.K.-S., M.Z., G.E.K., D.A.K.); and Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (T.N., K.T.)
| | - Kenichi Tsujita
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (T.N., G.Z., M.J.R., K.K.-S., M.Z., G.E.K., D.A.K.); and Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (T.N., K.T.)
| | - David A Kass
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (T.N., G.Z., M.J.R., K.K.-S., M.Z., G.E.K., D.A.K.); and Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (T.N., K.T.).
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27
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Narvaez-Guerra O, Herrera-Enriquez K, Medina-Lezama J, Chirinos JA. Systemic Hypertension at High Altitude. Hypertension 2019; 72:567-578. [PMID: 30354760 DOI: 10.1161/hypertensionaha.118.11140] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Offdan Narvaez-Guerra
- From the Santa María Catholic University and PREVENCION Research Institute, Arequipa, Peru (O.N.-G., K.H.-E., J.M.-L.)
| | - Karela Herrera-Enriquez
- From the Santa María Catholic University and PREVENCION Research Institute, Arequipa, Peru (O.N.-G., K.H.-E., J.M.-L.)
| | - Josefina Medina-Lezama
- From the Santa María Catholic University and PREVENCION Research Institute, Arequipa, Peru (O.N.-G., K.H.-E., J.M.-L.)
| | - Julio A Chirinos
- University of Pennsylvania Perelman School of Medicine and Hospital of the University of Pennsylvania, Philadelphia (J.A.C.)
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28
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Schiattarella GG, Altamirano F, Tong D, French KM, Villalobos E, Kim SY, Luo X, Jiang N, May HI, Wang ZV, Hill TM, Mammen PPA, Huang J, Lee DI, Hahn VS, Sharma K, Kass DA, Lavandero S, Gillette TG, Hill JA. Nitrosative stress drives heart failure with preserved ejection fraction. Nature 2019; 568:351-356. [PMID: 30971818 PMCID: PMC6635957 DOI: 10.1038/s41586-019-1100-z] [Citation(s) in RCA: 447] [Impact Index Per Article: 89.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/07/2019] [Indexed: 12/21/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a common syndrome with high morbidity and mortality for which there are no evidence-based therapies. Here we report that concomitant metabolic and hypertensive stress in mice-elicited by a combination of high-fat diet and inhibition of constitutive nitric oxide synthase using Nω-nitro-L-arginine methyl ester (L-NAME)-recapitulates the numerous systemic and cardiovascular features of HFpEF in humans. Expression of one of the unfolded protein response effectors, the spliced form of X-box-binding protein 1 (XBP1s), was reduced in the myocardium of our rodent model and in humans with HFpEF. Mechanistically, the decrease in XBP1s resulted from increased activity of inducible nitric oxide synthase (iNOS) and S-nitrosylation of the endonuclease inositol-requiring protein 1α (IRE1α), culminating in defective XBP1 splicing. Pharmacological or genetic suppression of iNOS, or cardiomyocyte-restricted overexpression of XBP1s, each ameliorated the HFpEF phenotype. We report that iNOS-driven dysregulation of the IRE1α-XBP1 pathway is a crucial mechanism of cardiomyocyte dysfunction in HFpEF.
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Affiliation(s)
- Gabriele G Schiattarella
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Francisco Altamirano
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dan Tong
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kristin M French
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Elisa Villalobos
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Soo Young Kim
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Xiang Luo
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nan Jiang
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Herman I May
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Zhao V Wang
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Theodore M Hill
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Pradeep P A Mammen
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jian Huang
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dong I Lee
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Virginia S Hahn
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kavita Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - David A Kass
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sergio Lavandero
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Chemical & Pharmaceutical Sciences and Faculty of Medicine, University of Chile, Santiago, Chile
- Center for Molecular Studies of the Cell (CEMC), Institute of Biomedical Sciences (ICBM), Faculty of Medicine, University of Chile, Santiago, Chile
| | - Thomas G Gillette
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Joseph A Hill
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
- Department of Molecular Biology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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29
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Affiliation(s)
- Kavita Sharma
- From the Division of Cardiology, Department of Medicine and Department of Pharmacology and Molecular Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - David A Kass
- From the Division of Cardiology, Department of Medicine and Department of Pharmacology and Molecular Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD.
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30
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Arterial Stiffness and Ventricular Arterial Coupling and Pulsatative Load on the Left Ventricle in Patients with Hypertension with Initial and Fulminant Heart Failure and Preserved Ejection Fraction According to E/e’ Estimates. Fam Med 2018. [DOI: 10.30841/2307-5112.5.2018.166802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
Nitric oxide (NO), generated from L-arginine and oxygen by NO synthases, is a pleiotropic signaling molecule involved in cardiovascular and metabolic regulation. More recently, an alternative pathway for the formation of this free radical has been explored. The inorganic anions nitrate (NO3-) and nitrite (NO2-), originating from dietary and endogenous sources, generate NO bioactivity in a process involving seemingly symbiotic oral bacteria and host enzymes in blood and tissues. The described cardio-metabolic effects of dietary nitrate from experimental and clinical studies include lowering of blood pressure, improved endothelial function, increased exercise performance, and reversal of metabolic syndrome, as well as antidiabetic effects. The mechanisms underlying the salutary metabolic effects of nitrate are being revealed and include interaction with mitochondrial respiration, activation of key metabolic regulatory pathways, and reduction of oxidative stress. Here we review the recent advances in the nitrate-nitrite-NO pathway, focusing on metabolic effects in health and disease.
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32
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Harada E, Mizuno Y, Kugimiya F, Shono M, Maeda H, Yano N, Yasue H. Sex Differences in Heart Failure With Preserved Ejection Fraction Reflected by B-type Natriuretic Peptide Level. Am J Med Sci 2018; 356:335-343. [PMID: 30360801 DOI: 10.1016/j.amjms.2018.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 05/28/2018] [Accepted: 06/08/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Prevalence of heart failure with preserved ejection fraction (HFpEF) increases with advancing age, particularly among women. Plasma levels of B-type natriuretic peptide (BNP), a surrogate marker of heart failure, have consistently been shown to be higher in women in the general populations. Whether BNP levels differ as per the sex of HFpEF patients remains largely unknown. MATERIALS AND METHODS The study subjects were 733 HFpEF patients (204 men and 529 women, aged 80.9 ± 9.6 years) who underwent echocardiography and routine clinical examination, including plasma BNP level evaluation. These parameters were compared between women and men. RESULTS Plasma levels of BNP were significantly lower in women than in men (104 [61, 192] versus 133 [78, 255] pg/mL, P < 0.001), just as hemoglobin, atrial fibrillation, diabetes mellitus, beta-blockers, left ventricular diastolic dimension, left ventricular mass index, left ventricular eccentric hypertrophy and left atrial dimension were. Age, systolic blood pressure, pulse pressure, heart rate, left ventricular relative wall thickness, left ventricular ejection fraction and left ventricular concentric hypertrophy were higher in women than in men. Multiple regression analyses revealed that left ventricular mass index, body mass index, the ratio of early diastolic mitral flow velocity to tissue annular motion velocity divided by left ventricular diastolic dimension, estimated glomerular filtration rate, beta-blockers, left atrial dimensions, female sex and atrial fibrillation were significant predictors for BNP levels (t = 5.41, P < 0.001; t = -4.06, P < 0.001; t = 3.76, P < 0.001; t = -3.68, P < 0.001; t = 3.32, P = 0.001; t = 3.11, P = 0.002; t = -3.07, P = 0.002; and t = 2.65, P = 0.008, respectively). CONCLUSIONS Plasma BNP levels were lower in women and were related to left ventricular concentric remodeling and hypertrophy among HFpEF patients, contrary to those in the general population.
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Affiliation(s)
- Eisaku Harada
- Division of Cardiovascular Medicine, Kumamoto Kinoh Hospital, Kumamoto Aging Research Institute, Kumamoto, Japan
| | - Yuji Mizuno
- Division of Cardiovascular Medicine, Kumamoto Kinoh Hospital, Kumamoto Aging Research Institute, Kumamoto, Japan
| | - Fumihito Kugimiya
- Division of Cardiovascular Medicine, Kumamoto Kinoh Hospital, Kumamoto Aging Research Institute, Kumamoto, Japan
| | - Makoto Shono
- Division of Cardiovascular Medicine, Kumamoto Kinoh Hospital, Kumamoto Aging Research Institute, Kumamoto, Japan
| | - Hiroyuki Maeda
- Division of Cardiovascular Medicine, Kumamoto Kinoh Hospital, Kumamoto Aging Research Institute, Kumamoto, Japan
| | - Naotsugu Yano
- Division of Cardiovascular Medicine, Kumamoto Kinoh Hospital, Kumamoto Aging Research Institute, Kumamoto, Japan
| | - Hirofumi Yasue
- Division of Cardiovascular Medicine, Kumamoto Kinoh Hospital, Kumamoto Aging Research Institute, Kumamoto, Japan.
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33
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Londono-Hoyos F, Zamani P, Beraun M, Vasim I, Segers P, Chirinos JA. Effect of organic and inorganic nitrates on cerebrovascular pulsatile power transmission in patients with heart failure and preserved ejection fraction. Physiol Meas 2018; 39:044001. [PMID: 29488900 DOI: 10.1088/1361-6579/aab2ef] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Increased penetration of pulsatile power to the brain has been implicated in the pathogenesis of age-related cognitive dysfunction and dementia, a common comorbidity in patients with heart failure and preserved ejection fraction (HFpEF). However, there is a lack of knowledge on the effects of organic and inorganic nitrates administration in this population on the power carried by pressure and flow waves traveling through the proximal aorta and penetrating the carotid artery into the brain microvasculature. APPROACH We assessed aortic and carotid hemodynamics non-invasively in two sub-studies: (1) at baseline and after administration of 0.4 mg of sublingual nitroglycerine (an organic nitrate; n = 26); and (2) in a randomized controlled trial of placebo (PB) versus inorganic nitrate administration (beetroot-juice (BR), 12.9 mmol NO3; n = 16). MAIN RESULTS Wave and hydraulic power analysis demonstrated that NTG increased total hydraulic power (from 5.68% at baseline to 8.62%, P = 0.001) and energy penetration (from 8.69% to 11.63%; P = 0.01) from the aorta to the carotid, while inorganic nitrate administration did not induce significant changes in aortic and carotid wave power (power: 5.49%PB versus 6.25%BR, P = 0.49; energy: 8.89%PB versus 10.65%BR, P = 0.27). SIGNIFICANCE Organic nitrates, but not inorganic nitrates, increase the amount of hydraulic energy transmitted into the carotid artery in subjects with HFpEF. These findings may have implications for the adverse effect profiles of these agents (such as the differential incidence of headaches) and for the pulsatile hemodynamic stress of the brain microvasculature in this patient population.
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Affiliation(s)
- Francisco Londono-Hoyos
- University of Pennsylvania Perelman School of Medicine Hospital of the University of Pennsylvania, Philadelphia, PA, United States of America. Institute Biomedical Technology (IBiTech)-bioMMeda Research Group-Ghent University, Ghent, Belgium. FLH and PZ contributed equally to this manuscript
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Singh P, Vijayakumar S, Kalogeroupoulos A, Butler J. Multiple Avenues of Modulating the Nitric Oxide Pathway in Heart Failure Clinical Trials. Curr Heart Fail Rep 2018; 15:44-52. [DOI: 10.1007/s11897-018-0383-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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35
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Chirinos JA. The Nitrate-Nitrite-NO Pathway as a Novel Therapeutic Target in Heart Failure with Reduced Ejection Fraction. J Card Fail 2018; 24:74-77. [DOI: 10.1016/j.cardfail.2017.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 12/06/2017] [Accepted: 12/06/2017] [Indexed: 11/26/2022]
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36
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Divakaran S, Loscalzo J. The Role of Nitroglycerin and Other Nitrogen Oxides in Cardiovascular Therapeutics. J Am Coll Cardiol 2017; 70:2393-2410. [PMID: 29096811 DOI: 10.1016/j.jacc.2017.09.1064] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 09/19/2017] [Indexed: 11/19/2022]
Abstract
The use of nitroglycerin in the treatment of angina pectoris began not long after its original synthesis in 1847. Since then, the discovery of nitric oxide as a biological effector and better understanding of its roles in vasodilation, cell permeability, platelet function, inflammation, and other vascular processes have advanced our knowledge of the hemodynamic (mostly mediated through vasodilation of capacitance and conductance arteries) and nonhemodynamic effects of organic nitrate therapy, via both nitric oxide-dependent and -independent mechanisms. Nitrates are rapidly absorbed from mucous membranes, the gastrointestinal tract, and the skin; thus, nitroglycerin is available in a number of preparations for delivery via several routes: oral tablets, sublingual tablets, buccal tablets, sublingual spray, transdermal ointment, and transdermal patch, as well as intravenous formulations. Organic nitrates are commonly used in the treatment of cardiovascular disease, but clinical data limit their use mostly to the treatment of angina. They are also used in the treatment of subsets of patients with heart failure and pulmonary hypertension. One major limitation of the use of nitrates is the development of tolerance. Although several agents have been studied for use in the prevention of nitrate tolerance, none are currently recommended owing to a paucity of supportive clinical data. Only 1 method of preventing nitrate tolerance remains widely accepted: the use of a dosing strategy that provides an interval of no or low nitrate exposure during each 24-h period. Nitric oxide's important role in several cardiovascular disease mechanisms continues to drive research toward finding novel ways to affect both endogenous and exogenous sources of this key molecular mediator.
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Affiliation(s)
- Sanjay Divakaran
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph Loscalzo
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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37
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Lewis GA, Schelbert EB, Williams SG, Cunnington C, Ahmed F, McDonagh TA, Miller CA. Biological Phenotypes of Heart Failure With Preserved Ejection Fraction. J Am Coll Cardiol 2017; 70:2186-2200. [PMID: 29050567 DOI: 10.1016/j.jacc.2017.09.006] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 12/19/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) involves multiple pathophysiological mechanisms, which result in the heterogeneous phenotypes that are evident clinically, and which have potentially confounded previous HFpEF trials. A greater understanding of the in vivo human processes involved, and in particular, which are the causes and which are the downstream effects, may allow the syndrome of HFpEF to be distilled into distinct diagnoses based on the underlying biology. From this, specific interventions can follow, targeting individuals identified on the basis of their biological phenotype. This review describes the biological phenotypes of HFpEF and therapeutic interventions aimed at targeting these phenotypes.
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Affiliation(s)
- Gavin A Lewis
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, United Kingdom; University Hospital of South Manchester NHS Foundation Trust, Wythenshawe, Manchester, United Kingdom
| | - Erik B Schelbert
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; UPMC Cardiovascular Magnetic Resonance Center, Heart and Vascular Institute, Pittsburgh, Pennsylvania; Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Simon G Williams
- University Hospital of South Manchester NHS Foundation Trust, Wythenshawe, Manchester, United Kingdom
| | - Colin Cunnington
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Oxford Road, Manchester, United Kingdom
| | - Fozia Ahmed
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Oxford Road, Manchester, United Kingdom
| | | | - Christopher A Miller
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, United Kingdom; University Hospital of South Manchester NHS Foundation Trust, Wythenshawe, Manchester, United Kingdom; Wellcome Centre for Cell-Matrix Research, Division of Cell-Matrix Biology & Regenerative Medicine, School of Biology, Faculty of Biology, Medicine & Health, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, United Kingdom.
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38
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Jeong SO, Son Y, Lee JH, Choi SW, Kim SH, Cheong YK, Chung HT, Pae HO. Both nitric oxide and nitrite prevent homocysteine-induced endoplasmic reticulum stress and subsequent apoptosis via cGMP-dependent pathway in neuronal cells. Biochem Biophys Res Commun 2017; 493:164-169. [PMID: 28917840 DOI: 10.1016/j.bbrc.2017.09.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 09/12/2017] [Indexed: 01/05/2023]
Abstract
Growing evidence indicates that endoplasmic reticulum (ER) stress and/or ER stress-mediated apoptosis may play a role in the pathogenesis of neurodegenerative diseases such as Alzheimer's disease. The present study investigated the effects of non-cytotoxic concentrations of nitric oxide (NO) and nitrite, a metabolite of NO, on ER stress and ER stress-mediated apoptosis in Neuro-2a cells exposed to homocysteine (Hcy), an endogenous ER stress inducer. Hcy induced ER stress, as confirmed by inositol-requiring enzyme 1α (IRE1α) phosphorylation and X-box-binding protein-1 (Xbp1) mRNA splicing as well as C/EBP homologous protein (CHOP) expression, and apoptosis, as verified by Annexin V-positive cells. Surprisingly, non-cytotoxic NO (S-nitrosoglutathione) and nitrite markedly reduced Hcy-induced IRE1α phosphorylation, Xbp1 mRNA splicing, CHOP expression, and Annexin V-positive cells, indicating the cytoprotection of NO and nitrite against Hcy-induced ER stress and apoptosis. Moreover, inhibition of sGC/cGMP pathway abolished the cytoprotective effects of NO and nitrite, whereas cellular elevation of cGMP levels mimicked the cytoprotective actions of NO and nitrite. These findings provide the first evidence showing that both NO and nitrite can reduce ER stress and subsequent apoptosis via NO-sGC-cGMP pathway in neuronal cells and suggesting that NO and/or nitrite may have therapeutic value in the treatment of ER stress-associated neurodegenerative diseases.
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Affiliation(s)
- Sun-Oh Jeong
- Department of Microbiology and Immunology, Wonkwang University School of Medicine, 460 Iksandae-ro, Iksan 54538, Republic of Korea
| | - Yong Son
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, 460 Iksandae-ro, Iksan 54538, Republic of Korea
| | - Ju Hwan Lee
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, 460 Iksandae-ro, Iksan 54538, Republic of Korea
| | - Seung Won Choi
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, 460 Iksandae-ro, Iksan 54538, Republic of Korea
| | - Sung Hun Kim
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, 460 Iksandae-ro, Iksan 54538, Republic of Korea
| | - Yong-Kwan Cheong
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, 460 Iksandae-ro, Iksan 54538, Republic of Korea
| | - Hun-Taeg Chung
- Department of Biological Science, University of Ulsan, 30 Daehack-ro, Ulsan 44610, Republic of Korea.
| | - Hyun-Ock Pae
- Department of Microbiology and Immunology, Wonkwang University School of Medicine, 460 Iksandae-ro, Iksan 54538, Republic of Korea.
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39
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Patel JN, Shah SJ. Inorganic vs. organic nitrates for heart failure with preserved ejection fraction: it's not all in your head! Eur J Heart Fail 2017; 19:1516-1519. [PMID: 28891242 DOI: 10.1002/ejhf.966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 07/23/2017] [Indexed: 01/08/2023] Open
Affiliation(s)
- Jay N Patel
- Division of Cardiology, Department of Medicine, University of Illinois College of Medicine, Peoria, IL, USA
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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40
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Chirinos JA, Londono-Hoyos F, Zamani P, Beraun M, Haines P, Vasim I, Varakantam S, Phan TS, Cappola TP, Margulies KB, Townsend RR, Segers P. Effects of organic and inorganic nitrate on aortic and carotid haemodynamics in heart failure with preserved ejection fraction. Eur J Heart Fail 2017; 19:1507-1515. [PMID: 28547861 DOI: 10.1002/ejhf.885] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 04/04/2017] [Accepted: 04/10/2017] [Indexed: 01/23/2023] Open
Abstract
AIMS To assess the haemodynamic effects of organic vs. inorganic nitrate administration among patients with heart failure with preserved ejection fraction (HFpEF). METHODS AND RESULTS We assessed carotid and aortic pressure-flow relations non-invasively before and after the administration of 0.4 mg of sublingual nitroglycerin (n = 26), and in a separate sub-study, in response to 12.9 mmoL of inorganic nitrate (n = 16). Nitroglycerin did not consistently reduce wave reflections arriving at the proximal aorta (change in real part of reflection coefficient, 1st harmonic: -0.09; P = 0.01; 2nd harmonic: -0.045, P = 0.16; 3rd harmonic: +0.087; P = 0.05), but produced profound vasodilatation in the carotid territory, with a significant reduction in systolic blood pressure (133.6 vs. 120.5 mmHg; P = 0.011) and a marked reduction in carotid bed vascular resistance (19 580 vs. 13 078 dynes · s/cm5 ; P = 0.001) and carotid characteristic impedance (3440 vs. 1923 dynes · s/cm5 ; P = 0.002). Inorganic nitrate, in contrast, consistently reduced wave reflections across the first three harmonics (change in real part of reflection coefficient, 1st harmonic: -0.12; P = 0.03; 2nd harmonic: -0.11, P = 0.01; 3rd harmonic: -0.087; P = 0.09) and did not reduce blood pressure, carotid bed vascular resistance, or carotid characteristic impedance (P = NS). CONCLUSIONS Nitroglycerin produces marked vasodilatation in the carotid circulation, with a pronounced reduction in blood pressure and inconsistent effects on central wave reflections. Inorganic nitrate, in contrast, produces consistent reductions in wave reflections, and unlike nitroglycerin, it does so without significant hypotension or cerebrovascular dilatation. These haemodynamic differences may underlie the different effects on exercise capacity and side effect profile of inorganic vs. organic nitrate in HFpEF.
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Affiliation(s)
- Julio A Chirinos
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Francisco Londono-Hoyos
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Institute of Biomedical Technology, Ghent University, Ghent, Belgium
| | - Payman Zamani
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Melissa Beraun
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Philip Haines
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Izzah Vasim
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Swapna Varakantam
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Timothy S Phan
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas P Cappola
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Kenneth B Margulies
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Raymond R Townsend
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick Segers
- Institute of Biomedical Technology, Ghent University, Ghent, Belgium
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41
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Grassi B, Majerczak J, Bardi E, Buso A, Comelli M, Chlopicki S, Guzik M, Mavelli I, Nieckarz Z, Salvadego D, Tyrankiewicz U, Skórka T, Bottinelli R, Zoladz JA, Pellegrino MA. Exercise training in Tgα q*44 mice during the progression of chronic heart failure: cardiac vs. peripheral (soleus muscle) impairments to oxidative metabolism. J Appl Physiol (1985) 2017; 123:326-336. [PMID: 28522765 DOI: 10.1152/japplphysiol.00342.2017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/15/2017] [Accepted: 05/16/2017] [Indexed: 12/16/2022] Open
Abstract
Cardiac function, skeletal (soleus) muscle oxidative metabolism, and the effects of exercise training were evaluated in a transgenic murine model (Tgαq*44) of chronic heart failure during the critical period between the occurrence of an impairment of cardiac function and the stage at which overt cardiac failure ensues (i.e., from 10 to 12 mo of age). Forty-eight Tgαq*44 mice and 43 wild-type FVB controls were randomly assigned to control groups and to groups undergoing 2 mo of intense exercise training (spontaneous running on an instrumented wheel). In mice evaluated at the beginning and at the end of training we determined: exercise performance (mean distance covered daily on the wheel); cardiac function in vivo (by magnetic resonance imaging); soleus mitochondrial respiration ex vivo (by high-resolution respirometry); muscle phenotype [myosin heavy chain (MHC) isoform content; citrate synthase (CS) activity]; and variables related to the energy status of muscle fibers [ratio of phosphorylated 5'-AMP-activated protein kinase (AMPK) to unphosphorylated AMPK] and mitochondrial biogenesis and function [peroxisome proliferative-activated receptor-γ coactivator-α (PGC-1α)]. In the untrained Tgαq*44 mice functional impairments of exercise performance, cardiac function, and soleus muscle mitochondrial respiration were observed. The impairment of mitochondrial respiration was related to the function of complex I of the respiratory chain, and it was not associated with differences in CS activity, MHC isoforms, p-AMPK/AMPK, and PGC-1α levels. Exercise training improved exercise performance and cardiac function, but it did not affect mitochondrial respiration, even in the presence of an increased percentage of type 1 MHC isoforms. Factors "upstream" of mitochondria were likely mainly responsible for the improved exercise performance.NEW & NOTEWORTHY Functional impairments in exercise performance, cardiac function, and soleus muscle mitochondrial respiration were observed in transgenic chronic heart failure mice, evaluated in the critical period between the occurrence of an impairment of cardiac function and the terminal stage of the disease. Exercise training improved exercise performance and cardiac function, but it did not affect the impaired mitochondrial respiration. Factors "upstream" of mitochondria, including an enhanced cardiovascular O2 delivery, were mainly responsible for the functional improvement.
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Affiliation(s)
- Bruno Grassi
- Department of Medicine, University of Udine, Udine, Italy; .,Institute of Bioimaging and Molecular Physiology, National Research Council, Milan, Italy
| | - Joanna Majerczak
- Department of Muscle Physiology, Faculty of Rehabilitation, University School of Physical Education, Krakow, Poland
| | - Eleonora Bardi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Alessia Buso
- Department of Medicine, University of Udine, Udine, Italy
| | - Marina Comelli
- Department of Medicine, University of Udine, Udine, Italy
| | - Stefan Chlopicki
- Jagiellonian Centre for Experimental Therapeutics, Jagiellonian University Medical College, Krakow, Poland.,Chair of Pharmacology, Jagiellonian University Medical College, Krakow, Poland
| | - Magdalena Guzik
- Department of Muscle Physiology, Faculty of Rehabilitation, University School of Physical Education, Krakow, Poland
| | - Irene Mavelli
- Department of Medicine, University of Udine, Udine, Italy
| | - Zenon Nieckarz
- Institute of Physics, Jagiellonian University, Krakow, Poland; and
| | - Desy Salvadego
- Department of Medicine, University of Udine, Udine, Italy
| | - Urszula Tyrankiewicz
- Department of Magnetic Resonance Imaging, Institute of Nuclear Physics, Polish Academy of Sciences, Krakow, Poland
| | - Tomasz Skórka
- Department of Magnetic Resonance Imaging, Institute of Nuclear Physics, Polish Academy of Sciences, Krakow, Poland
| | | | - Jerzy A Zoladz
- Jagiellonian Centre for Experimental Therapeutics, Jagiellonian University Medical College, Krakow, Poland
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Deep Phenotyping of Systemic Arterial Hemodynamics in HFpEF (Part 2): Clinical and Therapeutic Considerations. J Cardiovasc Transl Res 2017; 10:261-274. [PMID: 28401511 DOI: 10.1007/s12265-017-9736-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 01/30/2017] [Indexed: 01/09/2023]
Abstract
Multiple phase III trials over the last few decades have failed to demonstrate a clear benefit of various pharmacologic interventions in heart failure with a preserved left ventricular (LV) ejection fraction (HFpEF). Therefore, a better understanding of its pathophysiology is important. An accompanying review describes key technical and physiologic aspects regarding the deep phenotyping of arterial hemodynamics in HFpEF. This review deals with the potential of this approach to enhance our clinical, translational, and therapeutic approach to HFpEF. Specifically, the role of arterial hemodynamics is discussed in relation to (1) the pathophysiology of left ventricular diastolic dysfunction, remodeling, and fibrosis, (2) impaired oxygen delivery to peripheral skeletal muscle, which affects peripheral oxygen extraction, (3) the frequent presence of comorbidities, such as renal failure and dementia in this population, and (4) the potential to enhance precision medicine approaches. A therapeutic approach to target arterial hemodynamic abnormalities that are prevalent in this population (particularly, with inorganic nitrate/nitrite) is also discussed.
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43
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Deep Phenotyping of Systemic Arterial Hemodynamics in HFpEF (Part 1): Physiologic and Technical Considerations. J Cardiovasc Transl Res 2017; 10:245-259. [PMID: 28210939 DOI: 10.1007/s12265-017-9735-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 01/30/2017] [Indexed: 01/20/2023]
Abstract
A better understanding of the pathophysiology of heart failure with a preserved left ventricular ejection fraction (HFpEF) is important. Detailed phenotyping of pulsatile hemodynamics has provided important insights into the pathophysiology of left ventricular remodeling and fibrosis, diastolic dysfunction, microvascular disease, and impaired oxygen delivery to peripheral skeletal muscle, all of which contribute to exercise intolerance, the cardinal feature of HFpEF. Furthermore, arterial pulsatile hemodynamic mechanisms likely contribute to the frequent presence of comorbidities, such as renal failure and dementia, in this population. Our therapeutic approach to HFpEF can be enhanced by clinical phenotyping tools with the potential to "segment" this population into relevant pathophysiologic categories or to identify individuals exhibiting prominent specific abnormalities that can be targeted by pharmacologic interventions. This review describes relevant technical and physiologic aspects regarding the deep phenotyping of arterial hemodynamics in HFpEF. In an accompanying review, the potential of this approach to enhance our clinical and therapeutic approach to HFpEF is discussed.
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44
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Altara R, Giordano M, Nordén ES, Cataliotti A, Kurdi M, Bajestani SN, Booz GW. Targeting Obesity and Diabetes to Treat Heart Failure with Preserved Ejection Fraction. Front Endocrinol (Lausanne) 2017; 8:160. [PMID: 28769873 PMCID: PMC5512012 DOI: 10.3389/fendo.2017.00160] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 06/23/2017] [Indexed: 12/12/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a major unmet medical need that is characterized by the presence of multiple cardiovascular and non-cardiovascular comorbidities. Foremost among these comorbidities are obesity and diabetes, which are not only risk factors for the development of HFpEF, but worsen symptoms and outcome. Coronary microvascular inflammation with endothelial dysfunction is a common denominator among HFpEF, obesity, and diabetes that likely explains at least in part the etiology of HFpEF and its synergistic relationship with obesity and diabetes. Thus, pharmacological strategies to supplement nitric oxide and subsequent cyclic guanosine monophosphate (cGMP)-protein kinase G (PKG) signaling may have therapeutic promise. Other potential approaches include exercise and lifestyle modifications, as well as targeting endothelial cell mineralocorticoid receptors, non-coding RNAs, sodium glucose transporter 2 inhibitors, and enhancers of natriuretic peptide protective NO-independent cGMP-initiated and alternative signaling, such as LCZ696 and phosphodiesterase-9 inhibitors. Additionally, understanding the role of adipokines in HFpEF may lead to new treatments. Identifying novel drug targets based on the shared underlying microvascular disease process may improve the quality of life and lifespan of those afflicted with both HFpEF and obesity or diabetes, or even prevent its occurrence.
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Affiliation(s)
- Raffaele Altara
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
- KG Jebsen Center for Cardiac Research, Oslo, Norway
- Department of Pathology, School of Medicine, University of Mississippi Medical Center, Jackson, MS, United States
- *Correspondence: Raffaele Altara,
| | - Mauro Giordano
- Department of Medical, Surgical, Neurological, Metabolic and Geriatrics Sciences, University of Campania “L. Vanvitelli”, Caserta, Italy
| | - Einar S. Nordén
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
- KG Jebsen Center for Cardiac Research, Oslo, Norway
- Bjørknes College, Oslo, Norway
| | - Alessandro Cataliotti
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
- KG Jebsen Center for Cardiac Research, Oslo, Norway
| | - Mazen Kurdi
- Faculty of Sciences, Department of Chemistry and Biochemistry, Lebanese University, Hadath, Lebanon
| | - Saeed N. Bajestani
- Department of Pathology, School of Medicine, University of Mississippi Medical Center, Jackson, MS, United States
- Department of Ophthalmology, School of Medicine, University of Mississippi Medical Center, Jackson, MS, United States
| | - George W. Booz
- Department of Pharmacology and Toxicology, School of Medicine, University of Mississippi Medical Center, Jackson, MS, United States
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Abstract
Measures of interaction between the left ventricle (LV) and arterial system (ventricular-arterial coupling) are important but under-recognised cardiovascular phenotypes in heart failure. Ventriculo-arterial coupling is commonly assessed in the pressure-volume plane, using the ratio of effective arterial elastance (EA) to LV end-systolic elastance (EES) to provide information on ventricular-arterial system mechanical efficiency and performance when LV ejection fraction is abnormal. These analyses have significant limitations, such as neglecting systolic loading sequence, and are less informative in heart failure with preserved ejection fraction (HFpEF). EA is almost entirely dependent on vascular resistance and heart rate. Assessment of pulsatile arterial haemodynamics and time-resolved myocardial wall stress provide critical incremental physiological information and should be more widely utilised. Pulsatile arterial load represents a promising therapeutic target in HFpEF. Here, we review various approaches to assess ventricular-arterial interactions, and their pathophysiological and clinical implications in heart failure.
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Affiliation(s)
- Julio A Chirinos
- University of Pennsylvania Perelman School of Medicine and Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nancy Sweitzer
- Tucson and Arizona Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ, USA
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46
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Chirinos JA, Akers SR, Trieu L, Ischiropoulos H, Doulias PT, Tariq A, Vasim I, Koppula MR, Syed AA, Soto-Calderon H, Townsend RR, Cappola TP, Margulies KB, Zamani P. Heart Failure, Left Ventricular Remodeling, and Circulating Nitric Oxide Metabolites. J Am Heart Assoc 2016; 5:JAHA.116.004133. [PMID: 27742619 PMCID: PMC5121510 DOI: 10.1161/jaha.116.004133] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Stable plasma nitric oxide (NO) metabolites (NOM), composed predominantly of nitrate and nitrite, are attractive biomarkers of NO bioavailability. NOM levels integrate the influence of NO‐synthase‐derived NO production/metabolism, dietary intake of inorganic nitrate/nitrite, and clearance of NOM. Furthermore, nitrate and nitrite, the most abundant NOM, can be reduced to NO via the nitrate‐nitrite‐NO pathway. Methods and Results We compared serum NOM among subjects without heart failure (n=126), subjects with heart failure and preserved ejection fraction (HFpEF; n=43), and subjects with heart failure and reduced ejection fraction (HFrEF; n=32). LV mass and extracellular volume fraction were measured with cardiac MRI. Plasma NOM levels were measured after reduction to NO via reaction with vanadium (III)/hydrochloric acid. Subjects with HFpEF demonstrated significantly lower unadjusted levels of NOM (8.0 μmol/L; 95% CI 6.2–10.4 μmol/L; ANOVA P=0.013) than subjects without HF (12.0 μmol/L; 95% CI 10.4–13.9 μmol/L) or those with HFrEF (13.5 μmol/L; 95% CI 9.7–18.9 μmol/L). There were no significant differences in NOM between subjects with HFrEF and subjects without HF. In a multivariable model that adjusted for age, sex, race, diabetes mellitus, body mass index, current smoking, systolic blood pressure, and glomerular filtration rate, HFpEF remained a predictor of lower NOM (β=−0.43; P=0.013). NOM did not correlate with LV mass, or LV diffuse fibrosis. Conclusions HFpEF, but not HFrEF, is associated with reduced plasma NOM, suggesting greater endothelial dysfunction, enhanced clearance, or deficient dietary ingestion of inorganic nitrate. Our findings may underlie the salutary effects of inorganic nitrate supplementation demonstrated in recent clinical trials in HFpEF.
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Affiliation(s)
- Julio A Chirinos
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA University of Pennsylvania School of Medicine, Philadelphia, PA Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Lien Trieu
- Rowan University School of Osteopathic Medicine, Stratford, NJ
| | - Harry Ischiropoulos
- University of Pennsylvania School of Medicine, Philadelphia, PA Children's Hospital of Philadelphia Research Institute, Philadelphia, PA
| | - Paschalis-Thomas Doulias
- University of Pennsylvania School of Medicine, Philadelphia, PA Children's Hospital of Philadelphia Research Institute, Philadelphia, PA
| | - Ali Tariq
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Izzah Vasim
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Amer Ahmed Syed
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Raymond R Townsend
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Thomas P Cappola
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Kenneth B Margulies
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Payman Zamani
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA University of Pennsylvania School of Medicine, Philadelphia, PA
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47
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Abstract
Heart failure (HF) patients suffer from exercise intolerance that diminishes their ability to perform normal activities of daily living and hence compromises their quality of life. This is due largely to detrimental changes in skeletal muscle mass, structure, metabolism, and function. This includes an impairment of muscle contractile performance, i.e., a decline in the maximal force, speed, and power of muscle shortening. Although numerous mechanisms underlie this reduction in contractility, one contributing factor may be a decrease in nitric oxide (NO) bioavailability. Consistent with this, recent data demonstrate that acute ingestion of NO3 (-)-rich beetroot juice, a source of NO via the NO synthase-independent enterosalivary pathway, markedly increases maximal muscle speed and power in HF patients. This review discusses the role of muscle contractile dysfunction in the exercise intolerance characteristic of HF, and the evidence that dietary NO3 (-) supplementation may represent a novel and simple therapy for this currently underappreciated problem.
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Affiliation(s)
- Andrew R Coggan
- Cardiovascular Imaging Laboratory, Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd. - Campus Box 8225, St. Louis, MO, 63110, USA.
| | - Linda R Peterson
- Cardiovascular Imaging Laboratory, Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd. - Campus Box 8225, St. Louis, MO, 63110, USA
- Cardiovascular Division, Department of Internal Medicine, Washington University School of Medicine, 660 S. Euclid Ave. - Campus Box 8086, St. Louis, MO, 63110, USA
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