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Munir AZ, Gutierrez A, Qin J, Lichtman AH, Moslehi JJ. Immune-checkpoint inhibitor-mediated myocarditis: CTLA4, PD1 and LAG3 in the heart. Nat Rev Cancer 2024; 24:540-553. [PMID: 38982146 DOI: 10.1038/s41568-024-00715-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 07/11/2024]
Abstract
Immune-checkpoint inhibitors (ICIs) have revolutionized oncology, with nearly 50% of all patients with cancer eligible for treatment with ICIs. However, patients on ICI therapy are at risk for immune-related toxicities that can affect any organ. Inflammation of the heart muscle, known as myocarditis, resulting from ICI targeting cytotoxic T lymphocyte-associated antigen 4 (CTLA4), programmed cell death protein 1 (PD1) and PD1 ligand 1 (PDL1) is an infrequent but potentially fatal complication. ICI-mediated myocarditis (ICI-myocarditis) is a growing clinical entity given the widespread use of ICIs, its increased clinical recognition and growing use of combination ICI treatment, a well-documented risk factor for ICI-myocarditis. In this Review, we approach ICI-myocarditis from a basic and mechanistic perspective, synthesizing the recent data from both preclinical models and patient samples. We posit that mechanistic understanding of the fundamental biology of immune-checkpoint molecules may yield new insights into disease processes, which will enable improvement in diagnostic and therapeutic approaches. The syndrome of ICI-myocarditis is novel, and our understanding of immune checkpoints in the heart is in its nascency. Yet, investigations into the pathophysiology will inform better patient risk stratification, improved diagnostics and precision-based therapies for patients.
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Affiliation(s)
- Amir Z Munir
- Section of Cardio-Oncology & Immunology, Cardiovascular Research Institute (CVRI), University of California San Francisco, School of Medicine, San Francisco, CA, USA
| | - Alan Gutierrez
- Section of Cardio-Oncology & Immunology, Cardiovascular Research Institute (CVRI), University of California San Francisco, School of Medicine, San Francisco, CA, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Juan Qin
- Section of Cardio-Oncology & Immunology, Cardiovascular Research Institute (CVRI), University of California San Francisco, School of Medicine, San Francisco, CA, USA
| | - Andrew H Lichtman
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Javid J Moslehi
- Section of Cardio-Oncology & Immunology, Cardiovascular Research Institute (CVRI), University of California San Francisco, School of Medicine, San Francisco, CA, USA.
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Seidel F, Scheibenbogen C, Heidecke H, Opgen-Rhein B, Pickardt T, Klingel K, Berger F, Messroghli D, Schubert S. Compensatory Upregulation of Anti-Beta-Adrenergic Receptor Antibody Levels Might Prevent Heart Failure Presentation in Pediatric Myocarditis. Front Pediatr 2022; 10:881208. [PMID: 35573966 PMCID: PMC9096696 DOI: 10.3389/fped.2022.881208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Myocarditis can be associated with severe heart failure and is caused by different inflammatory and autoimmune responses. The aim of this study was to describe the immunological response in children with myocarditis by analyzing anti-beta-adrenergic receptor antibodies (anti-β-AR Abs). METHODS Sera of children who were hospitalized with biopsy-proven myocarditis were prospectively collected between April 2017 and March 2019. Anti-β1-AR Ab, anti-β2-AR Ab, and anti-β3-AR Ab were quantified by a CE-certified ELISA kit. According to normal values for immunoglobulin G (IgG), three age groups, <1, 1-5, and >5-17 years, were defined. Children without inflammatory cardiac pathology and no heart failure signs were served as a control group. RESULTS We compared 22 patients with biopsy-proven myocarditis and 28 controls. The median age (interquartile range) of the myocarditis group (MYC) was 12.1 (2.7-16.4) years, 13 men, left ventricular ejection fraction (LVEF) 51% and for control group, the median age was 5.0 (3.0-6.8) years, nine men, LVEF 64%. Myocarditis patients in the age group >5-17 years showed significantly higher anti-β3-AR Ab levels as compared to controls (p = 0.014). Lower anti-β2-AR Ab and anti-β3-AR Ab levels were significantly correlated with higher left ventricular diameters in myocarditis patients. The event-free survival using a combined endpoint (mechanical circulatory support [MCS], transplantation, and/or death) was significantly lower in myocarditis patients with antibody levels below the median as compared to myocarditis patients with antibody levels ≥ the median. CONCLUSION Anti-β-AR Ab levels are increased in children with myocarditis and >5 years of age. These antibodies might be upregulated compensatory to prevent further cardiac deterioration. A worse event-free survival in patients with lower anti-β-AR Ab levels might be a therapeutic target for immunoglobulin substitution.
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Affiliation(s)
- Franziska Seidel
- German Heart Center Berlin, Department of Congenital Heart Disease and Pediatric Cardiology, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Department of Pediatric Cardiology, Berlin, Germany.,Experimental and Clinical Research Center, a Cooperation between the Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association and the Charité - Universitätsmedizin Berlin, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Carmen Scheibenbogen
- Charité - Universitätsmedizin Berlin, Outpatient Clinic for Immunodeficiencies, Institute for Medical Immunology, Berlin, Germany
| | | | - Bernd Opgen-Rhein
- Charité - Universitätsmedizin Berlin, Department of Pediatric Cardiology, Berlin, Germany
| | - Thomas Pickardt
- Competence Network for Congenital Heart Diseases, Berlin, Germany
| | - Karin Klingel
- Department of Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Felix Berger
- German Heart Center Berlin, Department of Congenital Heart Disease and Pediatric Cardiology, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Department of Pediatric Cardiology, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Daniel Messroghli
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,German Heart Center Berlin, Department of Internal Medicine - Cardiology, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Department of Internal Medicine and Cardiology, Berlin, Germany
| | - Stephan Schubert
- German Heart Center Berlin, Department of Congenital Heart Disease and Pediatric Cardiology, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Center for Congenital Heart Disease/Pediatric Cardiology, Heart and Diabetes Center NRW, University Clinic of Ruhr-University Bochum, Bad Oeynhausen, Germany
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Viruses in the Heart: Direct and Indirect Routes to Myocarditis and Heart Failure. Viruses 2021; 13:v13101924. [PMID: 34696354 PMCID: PMC8537553 DOI: 10.3390/v13101924] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/09/2021] [Accepted: 09/21/2021] [Indexed: 01/01/2023] Open
Abstract
Viruses are an underappreciated cause of heart failure. Indeed, several types of viral infections carry cardiovascular risks. Understanding shared and unique mechanisms by which each virus compromises heart function is critical to inform on therapeutic interventions. This review describes how the key viruses known to lead to cardiac dysfunction operate. Both direct host-damaging mechanisms and indirect actions on the immune systems are discussed. As viral myocarditis is a key pathologic driver of heart failure in infected individuals, this review also highlights the role of cytokine storms and inflammation in virus-induced cardiomyopathy.
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Roles of Host Immunity in Viral Myocarditis and Dilated Cardiomyopathy. J Immunol Res 2018; 2018:5301548. [PMID: 29854842 PMCID: PMC5964556 DOI: 10.1155/2018/5301548] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 04/09/2018] [Accepted: 04/19/2018] [Indexed: 02/07/2023] Open
Abstract
The pathogenesis of viral myocarditis includes both the direct damage mediated by viral infection and the indirect lesion resulted from host immune responses. Myocarditis can progress into dilated cardiomyopathy that is also associated with immunopathogenesis. T cell-mediated autoimmunity, antibody-mediated autoimmunity (autoantibodies), and innate immunity, working together, contribute to the development of myocarditis and dilated cardiomyopathy.
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Yang F, Mo WH, Tan BP, Wei XM, Wang H. Increased frequency of follicular helper T cells in mice viral myocarditis is relevant with anti-ANT antoantibody. Virol J 2015; 12:20. [PMID: 25889760 PMCID: PMC4349663 DOI: 10.1186/s12985-015-0257-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Accepted: 02/02/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Recently, a new subset of CD4(+)T helper cell termed Follicular helper T cells (Tfh), which play a pivotal role in B cell activation and differentiation in lymphoid structures, has been reported to participate in some certain autoimmune diseases. But whether Tfh cells are involved in the pathogenesis of VMC remains unclear. METHODS Male BALB/c mice were intraperitoneally (i.p) infected with CVB3 to establish VMC models. Control mice were treated with phosphate-buffered saline i.p. On 0, 1, 2, 3, 4, 6 weeks post injection, frequencies of splenic Tfh cells were determined by flow cytometric analysis, productions of IL-21 and anti-adenine nucleotide translocator(ANT) autoantibody were detected by enzyme-linked immunosorbent assay. To further investigate the effects of Tfh cells, VMC mice were treated with Anti-IL-21 neutralizing antibody. Heart pathology was examined histologically, the frequencies of Tfh cells and the expressions of anti-ANT autoantibody were investigated after anti-IL-21 intervention. Spearman analysis was used to evaluate the relationship between the frequencies of Tfh cells and IL-21 levels with anti-ANT autoantibody. RESULTS The percentage of Tfh cells significantly increased in VMC mice from 1 W to 6 W, the serum level of IL-21 and ANT autoantibody were also significantly increased in VMC mice. Neutralization of IL-21 with anti-IL-21 can ameliorate the myocardium inflammation, decrease Tfh cells and ANT autoantibody after IL-21 antibody intervention compared with those of the control (P < 0.05). Both of the frequencies of Tfh cells and IL-21 levels were positively correlated with anti-ANT antibody levels (R = 0.758, P < 0.05; R = 0.88, P < 0.01, respectively). CONCLUSIONS Those results suggest that Tfh cells and IL-21 might involve in the pathogenesis of VMC and play an important role in anti-ANT autoantibody production. Targeting the Tfh cell and IL-21 may be a new therapeutic target for the treatment of CVB3-induced VMC.
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Affiliation(s)
- Fan Yang
- Department of Cardiology, the Fourth Affiliated Hospital of Guangxi Medical University, Liu-Shi Road 1, 545005, Liuzhou, China.
| | - Wen-hong Mo
- Department of Cardiology, the Fourth Affiliated Hospital of Guangxi Medical University, Liu-Shi Road 1, 545005, Liuzhou, China.
| | - Bao-ping Tan
- Department of Cardiology, the Fourth Affiliated Hospital of Guangxi Medical University, Liu-Shi Road 1, 545005, Liuzhou, China.
| | - Xiao-mou Wei
- Department of Cardiology, the Fourth Affiliated Hospital of Guangxi Medical University, Liu-Shi Road 1, 545005, Liuzhou, China.
| | - Hong Wang
- Department of Cardiology, the Fourth Affiliated Hospital of Guangxi Medical University, Liu-Shi Road 1, 545005, Liuzhou, China.
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Induction of cardiomyocyte apoptosis by anti-cardiac myosin heavy chain antibodies in patients with acute myocardial infarction. ACTA ACUST UNITED AC 2010; 30:582-8. [DOI: 10.1007/s11596-010-0546-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Indexed: 12/13/2022]
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Neutralization of IL-17 inhibits the production of anti-ANT autoantibodies in CVB3-induced acute viral myocarditis. Int Immunopharmacol 2010; 10:272-6. [DOI: 10.1016/j.intimp.2009.11.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2009] [Revised: 11/12/2009] [Accepted: 11/12/2009] [Indexed: 11/16/2022]
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Kaya Z, Katus HA, Rose NR. Cardiac troponins and autoimmunity: their role in the pathogenesis of myocarditis and of heart failure. Clin Immunol 2009; 134:80-8. [PMID: 19446498 DOI: 10.1016/j.clim.2009.04.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Revised: 04/16/2009] [Accepted: 04/19/2009] [Indexed: 01/22/2023]
Abstract
Despite the widespread use of cardiac troponins as biomarkers for the diagnosis and quantitation of cardiac injury, the effect of troponin release and a possible autoimmune response to the troponins is unknown. Other investigators reported that programmed cell death-1 (PD-1)-receptor deficient mice developed severe cardiomyopathy with autoantibodies to troponin I. We found that immunization of genetically susceptible mice with troponin I but not troponin T induced a robust autoimmune response leading to marked inflammation and fibrosis in the myocardium. At later times, antibodies to cardiac myosin were detected in troponin-immunized mice. The severity of inflammation correlated with expression of chemokines RANTES, MIP-2, IP-10 and MCP-1 in the myocardium. Prior immunization with troponin I increased the severity of experimental infarctions, indicating that an autoimmune response to troponin I aggravates acute cardiac damage. Cardiac inflammation, fibrosis and functional impairment were transferred from immunized to naive recipients by CD4+ T cells, and the cytokine profile suggested both Th2 and Th17 profiles in A/J mice. Finally we identified an 18-mer of troponin I containing an immuno-dominant epitope.
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Affiliation(s)
- Ziya Kaya
- Department of Cardiology, University of Heidelberg, 69120 Heidelberg, Germany.
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Ebermann L, Piper C, Kühl U, Klingel K, Schlattner U, Siafarikas N, Zeichhardt H, Schultheiss HP, Dörner A. Impact of myocardial inflammation on cytosolic and mitochondrial creatine kinase activity and expression. Basic Res Cardiol 2009; 104:247-57. [PMID: 19190956 DOI: 10.1007/s00395-008-0773-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Accepted: 12/05/2008] [Indexed: 11/26/2022]
Abstract
The disturbance of myocardial energy metabolism has been discussed as contributing to the progression of heart failure. Little however is known about the cardiac mitochondrial/cytosolic energy transfer in murine and human inflammatory heart disease. We examined the myocardial creatine kinase (CK) system, which connects mitochondrial ATP-producing and cytosolic ATP-consuming processes and is thus of central importance to the cellular energy homeostasis. The time course of expression and enzymatic activity of mitochondrial (mtCK) and cytosolic CK (cytCK) was investigated in Coxsackievirus B3 (CVB3)-infected SWR mice, which are susceptible to the development of chronic myocarditis. In addition, cytCK activity and isoform expression were analyzed in biopsies from patients with chronic inflammatory heart disease (n = 22). Cardiac CVB3 titer in CVB3-infected mice reached its maximum at 4 days post-infection (pi) and became undetectable at 28 days pi; cardiac inflammation cumulated 14 days pi but persisted through the 28-day survey. MtCK enzymatic activity was reduced by 40% without a concurrent decrease in mtCK protein during early and acute MC. Impaired mtCK activity was correlated with virus replication and increased level of interleukine 1beta (IL-1beta), tumor necrosis factor alpha (TNFalpha), and elevated catalase expression, a marker for intracellular oxidative stress. A reduction in cytCK activity of 48% was observed at day 14 pi and persisted to day 28 pi. This restriction was caused by a decrease in cytCK subunit expression but also by direct inhibition of specific cytCK activity. CytCK activity and expression were also reduced in myocardial biopsies from enterovirus genome-negative patients with inflammatory heart disease. The decrease in cytCK activity correlated with the number of infiltrating macrophages. Thus, viral infection and myocardial inflammation significantly influence the myocardial CK system via restriction of specific CK activity and down-regulation of cytCK protein. These changes may contribute to the progression of chronic inflammatory heart disease and malfunction of the heart.
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Affiliation(s)
- Linda Ebermann
- Centrum 11, Cardiology, Charité, University Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany
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Recent insights into the role of autoimmunity in idiopathic dilated cardiomyopathy. J Card Fail 2008; 14:521-30. [PMID: 18672201 DOI: 10.1016/j.cardfail.2008.02.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Revised: 02/21/2008] [Accepted: 02/27/2008] [Indexed: 11/23/2022]
Abstract
Dilated cardiomyopathy is a devastating disease associated with poor outcomes. Although the etiology of this disease remains largely unknown, so-called "idiopathic" dilated cardiomyopathy (iDCM) is associated with evidence of an autoimmune process that may be contributing to the pathophysiology of this disease. Indeed, iDCM shares many characteristics with other autoimmune diseases, including an association with systemic and organ-specific inflammation, an association with viral infections, a genetic predisposition, and a correlation with specific human leukocyte antigen subtypes. Additionally, numerous pathologic cardiac-specific autoantibodies have been associated with iDCM, including those against alpha-myosin, the beta(1)-adrenoceptor, and cardiac troponin I. This review highlights the emerging evidence regarding autoimmune characteristics of iDCM, and summarizes the data of specific immunomodulatory therapies used to target autoimmune mechanisms in the treatment of patients with this devastating disease.
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