Anti-inflammatory therapy for heart failure

Nuclear Factor-κB is a Prime Candidate for the Diagnosis and Control of Inflammatory Cardiovascular Disease

Nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) is responsible for the regulation of genes involved in inflammation and immune responses. NF-κB may play an important role in cardiovascular diseases (CVDs), atherosclerosis and diabetes. Several therapeutic agents used for the treatment of CVDs and diabetes, such as pimobendan and sodium-glucose cotransporter 2 inhibitors, exert anti-inflammatory effects by inhibiting NF-κB activation; anti-inflammatory therapy may have beneficial effects in CVDs and diabetes. Several pharmacological agents and natural compounds may inhibit NF-κB, and these agents alone or in combination may be used to treat various inflammatory diseases. Immunoglobulin-free light chains could be surrogate biomarkers of NF-κB activation and may be useful for evaluating the efficacy of these agents. This review discusses recent advances in our understanding of how the NF-κB signalling pathway controls inflammation, metabolism and immunity, and how improved knowledge of these pathways may lead to better diagnostics and therapeutics for various human diseases.

Targeting Inflammation in the Diagnosis, Management, and Prevention of Cardiovascular Diseases

Inflammation plays an important role in the development and progression of cardiovascular diseases (CVDs). Hypertension and hyperlipidemia are the key risk factors of CVDs and induce inflammation in the heart and vessels. Unhealthy diet, infection, and smoking coupled with genetic factors lead to the development of CVDs as well as induce inflammation. Risk factors of CVDs such as hypertension and hyperlipidemia along with diabetes activate nuclear factor kappa B, which regulates the transcription of immunoglobulin free light chain (FLC) κ in B cells and the production of multiple inflammatory molecules, leading to inflammation. FLCs are novel biomarkers of inflammation, and their levels have been associated with overall mortality in a general population and with cardiovascular outcomes. In this review, the role of inflammation in the pathogenesis of CVDs, new biomarkers of inflammation, and dietary options counterbalancing inflammatory processes, such as the polyphenol-rich French maritime pine bark extract Pycnogenol, are discussed.

Efficacy and safety of electroacupuncture in acute decompensated heart failure: a study protocol for a randomized, patient- and assessor-blinded, sham controlled trial

Background

The purpose of this trial is to evaluate the effectiveness and safety of electroacupuncture in the treatment of acute decompensated heart failure compared with sham electroacupuncture.

Methods

This protocol is for a randomized, sham controlled, patient- and assessor-blinded, parallel group, single center clinical trial that can overcome the limitations of previous trials examining acupuncture and heart failure. Forty-four acute decompensated heart failure patients admitted to the cardiology ward will be randomly assigned into the electroacupuncture treatment group (n = 22) or the sham electroacupuncture control group (n = 22). Participants will receive electroacupuncture treatment for 5 days of their hospital stay. The primary outcome of this study is the difference in total diuretic dose between the two groups during hospitalization. On the day of discharge, follow-up heart rate variability, routine blood tests, cardiac biomarkers, high-sensitivity C-reactive protein (hs-CRP) level, and N-terminal pro b-type natriuretic peptide (NT-pro BNP) level will be assessed. Four weeks after discharge, hs-CRP, NT-pro BNP, heart failure symptoms, quality of life, and a pattern identification questionnaire will be used for follow-up analysis. Six months after discharge, major cardiac adverse events and cardiac function measured by echocardiography will be assessed. Adverse events will be recorded during every visit.

Discussion

The result of this clinical trial will offer evidence of the effectiveness and safety of electroacupuncture for acute decompensated heart failure.

Trial registration

Clinical Research Information Service: KCT0002249.

Docosapentaenoic acid monoacylglyceride reduces inflammation and vascular remodeling in experimental pulmonary hypertension

n-3 Polyunsaturated fatty acids (n-3 PUFA) have been shown to reduce inflammation and proliferation of pulmonary artery smooth muscle cells under pathophysiological conditions. However, the anti-inflammatory effect of the newly synthesized docosapentaenoic acid monoacylglyceride (MAG-DPA) on key signaling pathways in pulmonary hypertension (PH) pathogenesis has yet to be assessed. The aim of the present study was to determine the effects of MAG-DPA on pulmonary inflammation and remodeling occurring in a rat model of PH, induced by a single injection of monocrotaline (MCT: 60 mg/kg). Our results demonstrate that MAG-DPA treatment for 3 wk following MCT injection resulted in a significant improvement of right ventricular hypertrophy (RVH) and a reduction in Fulton's Index (FI). Morphometric analyses revealed that the wall thickness of pulmonary arterioles was significantly lower in MCT + MAG-DPA-treated rats compared with controls. This result was further correlated with a decrease in Ki-67 immunostaining. Following MAG-DPA treatments, lipid analysis showed a consistent increase in DPA together with lower levels of arachidonic acid (AA), as measured in blood and tissue samples. Furthermore, in MCT-treated rats, oral administration of MAG-DPA decreased NF-κB and p38 MAPK activation, leading to a reduction in MMP-2, MMP-9, and VEGF expression levels in lung tissue homogenates. Altogether, these data provide new evidence regarding the mode of action of MAG-DPA in the prevention of pulmonary hypertension induced by MCT.

Platelet activating factor in heart failure: potential role in disease progression and novel target for therapy

Heart failure (HF) is a complex syndrome with cardiac, renal, neurohormonal and sympathetic nervous system's manifestations, the pathogenesis of which among others is connected to inflammation. PAF has local and systemic effects pertaining to HF progression since it causes a negative inotropic effect, it induces arrhythmias, it induces apoptosis and it is involved in inflammation and atherosclerosis. In the present review the role of PAF in HF will be thoroughly presented along with the relevant data on PAF enzymes and the potential role of PAF metabolic circuit as a novel pharmacological target.

Baseline and 6-Week follow-up levels of PAF and activity of its metabolic enzymes in patients with heart failure and healthy volunteers--a pilot study

This study aimed at evaluating the changes in platelet-activating factor (PAF) and its metabolic enzymes over a 6-week follow-up period in patients with newly diagnosed heart failure ([HF] n = 12) compared with age-, sex-, and BMI-matched apparently healthy volunteers (n = 10). The PAF, its key biosynthetic enzymes (lyso-PAF acetyltransferase [lyso-PAF-AT] and dithiothreitol [DTT]-insensitive CDP choline: 1-alkyl-2-acetyl-sn-glycerol cholinephosphotransferase [PAF-CPT]), and its catabolic isoenzymes (PAF-acetylhydrolase [PAF-AH] and lipoprotein-associated phospholipase A2 [Lp-PLA2]) were measured in serum and leukocytes of participants. At baseline, patients with HF had lower median activities of lyso-PAF-AT (P < .001) and PAF-CPT (P = .07) in parallel with PAF levels (P = .05) and higher activities of PAF-AH (P = .02) and Lp-PLA2 (P < .001) than controls. At follow-up, PAF-CPT and PAF levels marginally increased (P = .1), lyso-PAF-AT (P < .001) remained downregulated, while PAF-AH (P = .004) and Lp-PLA2 (P < .001) remained elevated compared with the controls. Newly diagnosed patients with HF under drug treatment have an affected profile of PAF biosynthetic enzymes and especially lyso-PAF-AT.

Use of non-steroidal anti-inflammatory drugs and risk of incident myocardial infarction and heart failure, and all-cause mortality in the Australian veteran community

AIMS

We studied the association between either non-selective NSAIDs (ns-NSAIDs), selective COX-2 inhibitors, or any NSAID and risk of incident myocardial infarction (MI) and heart failure (HF), and all-cause mortality in elderly subjects.

METHODS

We conducted a retrospective nested case-control study on Australian veterans using nationwide hospital admission and pharmacy dispensing data. We estimated adjusted odds ratios (OR) with 95% confidence intervals (CI) for the risk of events for three different measures of prescription supply exposure over the last 2 years: (i) supplied at least once, (ii) supply frequency: supplied more than twice within the last 30 days, once or twice within the last 30 days, and once or more 30 days to 2 years and (iii) total supplies.

RESULTS

We identified 83 623 cases and 1 662 099 matched controls (1:20) contributing 3 862 931 persons-years of observation. NSAID use at least once within the last 2 years did not significantly affect the risk of MI (OR 1.00, 95% CI 0.96, 1.04) but was associated with a mildly reduced risk of HF (OR 0.95, 95% CI 0.92, 0.98). There was a reduced all-cause mortality with at least one supply of either ns-NSAIDs (OR 0.94, 95% CI 0.90, 0.97), selective COX-2 inhibitors (OR 0.90, 95% CI 0.88, 0.93), or any NSAID (OR 0.87, 95% CI 0.85, 0.90). Risk of death was also inversely associated with the number of prescription supplies.

CONCLUSIONS

NSAID use is not associated with an increased risk of incident MI and HF but is associated with a reduction in all-cause mortality in Australian veterans.

Effects of telmisartan on markers of ventricular remodeling in patients with acute myocardial infarction: comparison with enalapril

Enalapril is effective in the suppression of left ventricular remodeling after acute myocardial infarction (AMI), but the effect of telmisartan is unclear. The consecutive 163 AMI patients underwent primary percutaneous coronary intervention and were randomized to telmisartan (n = 82) or enalapril (n = 81). Left ventriculography was performed in the acute and chronic (6 months) phases. Matrix metalloproteinase (MMP)-2 and MMP-9 activities were measured by zymography in the acute (days 1, 7, and 14) and chronic (6 months) phases. Plasma pentraxin3 (PTX3), a marker of vascular inflammation, was also measured. There were no adverse effects in the telmisartan group. The analysis of the left ventriculograms in the acute and chronic phases revealed no difference between the two groups. MMP-9 activities at days 7 and 14 and in the chronic phase were decreased compared to that at day 1 in both groups. MMP-2 activity was also decreased in the acute phase, but increased in the chronic phase in both groups. There was no difference in the plasma PTX3 level in the acute phase, but in the chronic phase, PTX3 was significantly lower in telmisartan than in enalapril group (2.6 ± 1.4 vs. 3.2 ± 1.6 ng/ml, p = 0.04). Telmisartan is well tolerated, shows similar effects on the markers of left ventricular remodeling to those of enalapril, and suppresses vascular inflammation more effectively than enalapril in AMI patients. Telmisartan can be an alternative to angiotensin converting enzyme inhibitor in patients with AMI.

Nifedipine inhibits the activation of inflammatory and immune reactions in viral myocarditis

AIMS

The aim of study is to investigate the effect of nifedipine on viral myocarditis in an animal model.

MAIN METHODS

Four-week-old male DBA/2 mice were inoculated with 2 pfu of encephalomyocarditis virus (EMCV) and randomized to nifedipine (n=10) or control (n=10) group. The control group was fed by regular chow and the nifedipine group contained 0.01% of nifedipine. Mast cell density was counted, and expressions of messenger RNAs of stem cell factor (SCF), matrix metalloproteinases (MMPs), pro-collagen I, mast cell proteases, tumor necrosis factor-alpha (TNF-alpha), and interleukin-6 (IL-6) were evaluated by RT-PCR.

KEY FINDINGS

The area of myocardial necrosis was smaller in the nifedipine vs the control group (mean+/-SD, 1.2+/-1.3% vs 3.8+/-1.8%, respectively, P<0.005). The mast cell density (count/mm(2)) was lower in the nifedipine vs the control group (mean+/-SD, 0.23+/-0.16 vs 1.08+/-0.45, respectively, P<0.0005). The expressions of MMPs, mast cell proteases, TNF-alpha, IL-6, SCF and pro-collagen I were lower in the nifedipine group than in the control group (P<0.05).

SIGNIFICANCE

Nifedipine inhibited the activation of various participants in inflammatory and immune reactions in EMCV myocarditis.

Prognostic value of high-sensitivity C-reactive protein in heart failure: a systematic review

BACKGROUND

Several studies have suggested that high-sensitivity C-reactive protein (hsCRP) is a strong independent predictor of acute myocardial infarction and cardiovascular death. In the specific heart failure (HF) context, a low-grade inflammatory state can contribute to HF progression.

AIMS

To perform a systematic review on the current knowledge about low-grade inflammation, as assessed by hsCRP, in the prediction of HF in general and in high-risk populations as well as its prognostic value in established HF.

METHODS

We used a computerized literature search in the Medline database using the following key words: C-Reactive Protein, Heart Failure, Cardiomyopathy, Cardiac Failure, Prognosis, and Death. Articles were selected if they had measurements of hsCRP in different patient samples and reference to outcomes in terms of morbidity and mortality.

RESULTS

hsCRP is associated with incident HF in general and high-risk populations and provides prognostic information in HF patients. In almost all studies, the association of hsCRP with clinical events was independent of other baseline variables known to influence morbidity and mortality. Very different cutoffs have been proposed in each context across studies.

CONCLUSIONS

The prognostic power of hsCRP, whether we consider incident HF or adverse outcomes in established HF, is consistent in different patient populations.

Platelet activating factor (PAF) and activity of its biosynthetic and catabolic enzymes in blood and leukocytes of male patients with newly diagnosed heart failure

OBJECTIVES

To evaluate platelet activating factor (PAF) levels, its metabolic enzymes activity and its associations with other inflammatory markers in heart failure (HF) patients.

DESIGN AND METHODS

PAF, and two of its key biosynthetic enzymes [lyso-PAF acetyltransferase (lyso-PAF-AT) and DTT-insensitive CDP-choline:1-alkyl-2-acetyl-sn-glycerol cholinephosphotransferase (PAF-CPT)] along with its catabolic enzymes [PAF-acetylhydrolase (PAF-AH) and lipoprotein-associated phospholipase-A(2) (Lp-PLA(2))] were measured in serum and leukocytes of twelve newly diagnosed male HF patients. Serum CRP, TNF-alpha, IL-6, sCD14 and CD40L were also determined.

RESULTS

PAF ranged from 0.03 to 5.6 pmol/mL. Median lyso-PAF-AT, PAF-CPT, PAF-AH and Lp-PLA(2) activities were 4.1, 68.42, 644.44 pmol/min/mg protein and 51.42 pmol/min/microL correspondingly. Lyso-PAF-AT and PAF-CPT activities positively correlated with CRP, IL-6 and with each other, whereas PAF-CPT activity correlated with sCD14 and CD40L (P<0.05).

CONCLUSIONS

PAF's biosynthetic enzyme activities correlated with inflammatory and immunologic molecules, which are activated in HF. Our study indicates a potential role of PAF in HF patients.

Prognostic value of pentraxin 3 in patients with chronic heart failure

BACKGROUND

A long pentraxin, PTX3, is produced by vascular cells or inflammatory cells and released into the circulation, possibly reflecting local inflammation in the cardiovascular system.

AIM

This study was designed to assess the clinical significance of plasma pentraxin 3 (PTX3) levels in chronic heart failure (CHF).

METHODS

We measured plasma PTX3 levels in 37 patients with non-ischemic CHF (dilated cardiomyopathy) using enzyme-linked immunosorbent assay (ELISA) methods.

RESULTS

The plasma PTX3 levels were higher in CHF patients than in healthy subjects (P=0.001), and the CHF patients in the highest tertile of plasma PTX3 levels had more cardiac events than the patients in the lowest tertile (42% vs. 0%, P=0.02). Multivariate regression analysis showed that PTX3 was the most significant predictor of cardiac events (hazard ratio 1.912 for each increase in PTX3 of 1 ng/ml, P=0.019, 95% CI 1.114-3.282). In addition, PTX3 was strikingly expressed in human myocardial cells obtained from a biopsy specimen in a patient.

CONCLUSION

Plasma PTX3 levels might be a potentially useful biomarker to predict prognosis as well as to detect inflammatory status in patients with CHF.

beta-Agonist enhances type 2 T-cell survival and accumulation

BACKGROUND

Neurohumoral modulation of immune system function is poorly understood. beta-Adrenergic receptor ligands (beta-agonists) subserve numerous physiologic processes but also function as pathogenic or therapeutic agents in numerous diseases with inflammatory components.

OBJECTIVES

We sought to establish the effects of beta-agonists and prostaglandin E(2) (PGE(2)) on antigen-dependent and antigen-independent accumulation of IL-13(+) (type 2) and IFN-gamma(+) (type 1) T cells. We also sought to clarify the mechanisms mediating the effects of these G protein-coupled receptor agonists.

METHODS

Effects of beta-agonists or PGE(2) on T-cell subtype accumulation were assessed in peripheral blood lymphocytes cultured with alphaCD3/CD28 or IL-2 by using flow cytometry. The role of cyclic AMP-dependent protein kinase (PKA) in mediating agonist effects was assessed by means of characterization of (1) phosphorylation of an intracellular PKA substrate and (2) T cells from patients with lupus possessing a natural defect in PKA activation.

RESULTS

beta-Agonists, in contrast to PGE(2), increased IL-2-induced accumulation of human type 2 T cells, an effect attributable to differential activation of PKA affecting regulation of cell proliferation and apoptosis. In T cells from patients with lupus exhibiting defective PKA activation, both beta-agonists and PGE(2) promoted an increase in type 2 T-cell accumulation.

CONCLUSION

G(s)-coupled receptors have the capacity to elicit prosurvival signaling in type 2 T cells, which, in most instances, is obscured by concomitant and antimitogenic PKA activation.

CLINICAL IMPLICATIONS

beta-Agonists and other G(s)-coupled receptor agonists have the potential to regulate T-cell development to affect disease pathogenesis or the efficacy of therapies, and variability of effect relates to the ability to stimulate PKA activity.

High-sensitivity C-reactive protein and parameters of left ventricular dysfunction

BACKGROUND

Elevated levels of high-sensitivity C-reactive protein (CRP), an inflammatory marker, have been associated with heart failure. However, it is not known which parameters of left ventricular dysfunction correlate with elevated levels of CRP.

METHODS AND RESULTS

In this cross-sectional study of 98 patients referred for cardiac catheterization, we investigated whether commonly used clinical indices of left ventricular dysfunction correlated with CRP levels. CRP levels were elevated to a greater degree in participants with diabetes mellitus (P =.006) and heart failure (P =.003). Increased CRP levels were associated with increased plasma levels of B-type natriuretic peptide (BNP; P =.0001), decreased left ventricular ejection fraction (LVEF; P =.02), and increased left-ventricular end-diastolic pressure (LVEDP; P =.0005). After multivariable adjustment, LVEDP and CRP were independently associated (P =.046).

CONCLUSION

CRP is increased in patients with heart failure. Of the clinical parameters of left ventricular dysfunction, direct measurement of left ventricular end-diastolic pressure is most closely associated with CRP.

Antiinflammatory Effects of Cardiac Resynchronization Therapy in Patients with Chronic Heart Failure

BACKGROUND

Cardiac resynchronization therapy (CRT) pacing has been proposed as an additional treatment to medical therapy to improve heart failure patients with left ventricular asynchrony. The aim of this study was to evaluate the influence of CRT treatment on proinflammatory cytokines in patients with heart failure.

METHODS

Twenty patients, with a mean age 64 +/- 2 years, with severe chronic heart failure NYHA class II-IV (mean ejection fraction 25 +/- 2%), were included in the study. Patients were treated with CRT pacing, after failure of optimal therapy. Blood samples were taken at baseline, 3 months after pacing therapy, and after a subsequent 3-month period of no pacing for the assessment of proinflammatory cytokines TNF-alpha and its receptors (sTNFR-I, sTNFR-II), IL-6, adhesion molecules sICAM-1 and sVCAM-1, and the apoptotic indices sFas and sFas-Ligand.

RESULTS

Levels of TNF-alpha, sTNFR-I, and sTNFR-II were reduced at the end of 3 months of CRT therapy and further reduced at the end of the no pacing period (P < 0.05, compared to baseline). Levels of IL-6 also declined after 3 months of CRT pacing (from 8.9 +/- 2.5 pg/mL to 4.7 +/- 1.3 pg/mL, P < 0.05) and this was maintained during the no pacing period (3.9 +/- 1.1 pg/mL P < 0.05 compared to baseline). The adhesion molecule sICAM-1 levels also reduced (from 265 +/- 17 ng/mL to 235 +/- 12, P < 0.05) after 3 months of CRT pacing and remained unchanged at the end of the no pacing period (219 +/- 12 ng/mL, P < 0.05 compared to baseline values).

CONCLUSION

Major proinflammatory cytokines and the adhesion molecule sICAM-1 are reduced with CRT therapy and this effect is maintained for at least 3 months after discontinuation of pacing.

The Role of Endothelin in Heart Failure

Current treatments for heart failure extend the life of the patient but do not stop the progression of the disease process. These treatments may not be addressing the underlying cause of cellular injury. The role of endothelin in cardiac remodeling and inflammation may be important in the progression of failure, and endothelin antagonists may be beneficial in treatment in combination with drugs already in use.

Targets for immunomodulation in cardiovascular disease – where are we now?

The recognition that inflammation plays an important role in most cardiovascular pathologies offers the potential for the development of new therapeutic targets. Heart failure and in-stent restenosis are two areas in which there have been very recent developments in identifying and targeting potential inflammatory mediators. The development of both broad anti-inflammatory strategies and more targeted approaches have confirmed that immunomodulation may have a beneficial effect on disease progression of restenosis and heart failure in experimental animals, while the results from clinical studies highlight the need to consider the inflammatory processes as a whole, rather than some aspects in isolation. This review briefly summarizes the key stimuli for initiating inflammation in cardiovascular disease, recent clinical and experimental developments in the search for appropriate anti-inflammatory strategies and considers the possible pitfalls and future challenges for developing this area.