Diabetic cardiomyopathy

Impact of Sex and Diabetes in Patients with Heart Failure

PURPOSE OF REVIEW

Heart failure (HF) is a complex clinical syndrome with a growing global health burden. This review explores the intersection of HF, diabetes mellitus, and sex, highlighting epidemiological patterns, pathophysiological mechanisms, and treatment implications.

RECENT FINDINGS

Despite similar HF prevalence in men and women, diabetes mellitus (DM) appears to exert a more pronounced impact on HF outcomes in women. Pathophysiological differences involve cardiovascular risk factors, severe left ventricular dysfunction, and coronary artery disease, as well as hormonal influences and inflammatory markers. Diabetic cardiomyopathy introduces a sex-specific challenge, with women experiencing common adverse outcomes related to increased fibrosis and myocardial remodeling. Treatment strategies, particularly sodium-glucose cotransporter 2 inhibitors, exhibit cardiovascular benefits, but their response may differ in women. The link between HF and DM is bidirectional, with diabetes significantly increasing the risk of HF, and vice versa. Additionally, the impact of diabetes on mortality appears more pronounced in women than in men, leading to a modification of the traditional gender gap observed in HF outcomes. A personalized approach is crucial, and further research to improve outcomes in the complex interplay of HF, diabetes, and sex is needed.

Update on clinical and experimental management of diabetic cardiomyopathy: addressing current and future therapy

Diabetic cardiomyopathy (DCM) is a severe secondary complication of type 2 diabetes mellitus (T2DM) that is diagnosed as a heart disease occurring in the absence of any previous cardiovascular pathology in diabetic patients. Although it is still lacking an exact definition as it combines aspects of both pathologies - T2DM and heart failure, more evidence comes forward that declares DCM as one complex disease that should be treated separately. It is the ambiguous pathological phenotype, symptoms or biomarkers that makes DCM hard to diagnose and screen for its early onset. This re-view provides an updated look on the novel advances in DCM diagnosis and treatment in the experimental and clinical settings. Management of patients with DCM proposes a challenge by itself and we aim to help navigate and advice clinicians with early screening and pharmacotherapy of DCM.

Cardioprotective role of diacerein in diabetic cardiomyopathy via modulation of inflammasome/caspase1/interleukin1β pathway in juvenile rats

Diabetes mellitus is a common metabolic disorder affecting different body organs; one of its serious complications is diabetic cardiomyopathy (DCM). Thus, finding more cardiopreserving agents to protect the heart against such illness is a critical task. For the first time, we planned to study the suspected role of diacerein (DIA) in ameliorating DCM in juvenile rats and explore different mechanisms mediating its effect including inflammasome/caspase1/interleukin1β pathway. Four-week-aged juvenile rats were randomly divided into groups; the control group, diacerein group, diabetic group, and diabetic-treated group. Streptozotocin (45 mg/kg) single intraperitoneal (i.p.) dose was administered for induction of type 1 diabetes on the 1st day which was confirmed by detecting blood glucose level. DIA was given in a dose of 50 mg/kg/day for 6 weeks to diabetic and non-diabetic rats, then we evaluated different inflammatory, apoptotic, and oxidative stress parameters. Induction of DCM succeeded as there were significant increases in cardiac enzymes, heart weights, fasting blood glucose level (FBG), and glycosylated hemoglobin (HbA1c) associated with elevated blood pressure (BP), histopathological changes, and increased caspase 3 immunoexpression. Furthermore, there was an increase of malondialdehyde (MDA), inflammasome, caspase1, angiotensin II, nuclear factor kappa-B (NF-κB), tumor necrosis factor-α (TNFα), and interleukin 1β (IL1β). However, antioxidant parameters such as reduced glutathione (GSH) and total antioxidant capacity (TAC) significantly declined. Fortunately, DIA reversed the diabetic cardiomyopathy changes mostly due to the observed anti-inflammatory, antioxidant, and anti-apoptotic properties with regulation of blood glucose level.DIA has an ability to regulate DCM-associated biochemical and histopathological disturbances.

An Overview of Diabetic Cardiomyopathy

Diabetic cardiomyopathy (DCM) is a myocardial disorder that is characterised by structural and functional abnormalities of the heart muscle in the absence of hypertension, valvular heart disease, congenital heart defects, or coronary artery disease (CAD). After witnessing a particular form of cardiomyopathy in diabetic individuals, Rubler et al. came up with the moniker diabetic cardiomyopathy in 1972. Four stages of DCM are documented, and the American College of Cardiology/American Heart Association Stage and New York Heart Association Class for HF have some overlap. Diabetes is linked to several distinct forms of heart failure. Around 40% of people with heart failure with preserved ejection fraction (HFpEF) have diabetes, which is thought to be closely associated with the pathophysiology of HFpEF. Diabetes and HF are uniquely associated in a bidirectional manner. When compared to the general population without diabetes, those with diabetes have a risk of heart failure that is up to four times higher. A biomarker is a trait that is reliably measured and assessed as a predictor of healthy biological activities, pathological processes, or pharmacologic responses to a clinical treatment. Several biomarker values have been discovered to be greater in patients with diabetes than in control subjects among those who have recently developed heart failure. Myocardial fibrosis and hypertrophy are the primary characteristics of DCM, and structural alterations in the diabetic myocardium are often examined by non-invasive, reliable, and reproducible procedures. An invasive method called endomyocardial biopsy (EMB) is most often used to diagnose many cardiac illnesses.

Efficacy of traditional Chinese medicine on diabetic cardiomyopathy in animal models: a systematic review and meta-analysis

Background: Diabetic cardiomyopathy (DCM) is a severe complication of diabetes that can diminish the quality of life in patients and is a leading cause of death. Research has demonstrated the effectiveness of Traditional Chinese Medicine (TCM) in reducing blood sugar levels and protecting cardiovascular function in both animal models and clinical research studies. Nevertheless, the efficacy of TCM in animal models of DCM has not been analyzed systematically. Method: We searched the following electronic bibliographic databases: Web of Science, PubMed, Cochrane Library, and CNKI(China National Knowledge Infrastructure). Studies that reported the efficacy of TCM in animals with DCM were included. The literature search was conducted using the terms. The data will be restricted from the year 2013 to 24 April 2023, 24 studies were included in the meta-analysis. Result: A total of 24 Traditional Chinese Medicine interventions and 2157 animals met the inclusion criteria. The pooled data revealed that TCM interventions resulted in significant improvements in body weight (BW), heart weight (HW) to body weight ratio (HW/BW), triglyceride (TG) and cholesterol (TC) levels, ejection fraction (EF), fractional shortening (FS) and E/A ratio. Subgroup analysis and meta-regression revealed that the type of TCM, duration of intervention, method of modeling, and animal species were potential sources of heterogeneity. Conclusion: TCM interventions were associated with significant improvements in body weight, heart weight to body weight ratio, triglyceride and cholesterol levels, left ventricular internal dimension in systole, ejection fraction, fractional shortening and E/A ratio. The heterogeneity in the results was found to be potentially due to the type of TCM, duration of intervention, method of modeling, and animal species, as shown in subgroup analysis and meta-regression. Systematic Review Registration: identifier CRD42023402908.

Pomegranate peel extract protects against the development of diabetic cardiomyopathy in rats by inhibiting pyroptosis and downregulating LncRNA-MALAT1

Background: Pyroptosis is an inflammatory programmed cell death accompanied by activation of inflammasomes and maturation of pro-inflammatory cytokines interleukin-1β (IL-1β) and IL-18. Pyroptosis is closely linked to the development of diabetic cardiomyopathy (DC). Pomegranate peel extract (PPE) exhibits a cardioprotective effect due to its antioxidant and anti-inflammatory properties. This study aimed to investigate the underlying mechanisms of the protective effect of PPE on the myocardium in a rat model of DC and determine the underlying molecular mechanism.

Methods: Type 1 diabetes (T1DM) was induced in rats by intraperitoneal injection of streptozotocin. The rats in the treated groups received (150 mg/kg) PPE orally and daily for 8 weeks. The effects on the survival rate, lipid profile, serum cardiac troponin-1, lipid peroxidation, and tissue fibrosis were assessed. Additionally, the expression of pyroptosis-related genes (NLRP3 and caspase-1) and lncRNA-MALAT1 in the heart tissue was determined. The PPE was analyzed using UPLC-MS/MS and NMR for characterizing the phytochemical content.

Results: Prophylactic treatment with PPE significantly ameliorated cardiac hypertrophy in the diabetic rats and increased the survival rate. Moreover, prophylactic treatment with PPE in the diabetic rats significantly improved the lipid profile, decreased serum cardiac troponin-1, and decreased lipid peroxidation in the myocardial tissue. Histopathological examination of the cardiac tissues showed a marked reduction in fibrosis (decrease in collagen volume and number of TGF-β-positive cells) and preservation of normal myocardial structures in the diabetic rats treated with PPE. There was a significant decrease in the expression of pyroptosis-related genes (NLRP3 and caspase-1) and lncRNA-MALAT1 in the heart tissue of the diabetic rats treated with PPE. In addition, the concentration of IL-1β and caspase-1 significantly decreased in the heart tissue of the same group. The protective effect of PPE on diabetic cardiomyopathy could be due to the inhibition of pyroptosis and downregulation of lncRNA-MALAT1. The phytochemical analysis of the PPE indicated that the major compounds were hexahydroxydiphenic acid glucoside, caffeoylquinic acid, gluconic acid, citric acid, gallic acid, and punicalagin.

Conclusion: PPE exhibited a cardioprotective potential in diabetic rats due to its unique antioxidant, anti-inflammatory, and antifibrotic properties and its ability to improve the lipid profile. The protective effect of PPE on DC could be due to the inhibition of the NLRP3/caspase-1/IL-1β signaling pathway and downregulation of lncRNA-MALAT1. PPE could be a promising therapy to protect against the development of DC, but further clinical studies are recommended.

An Integrative Pharmacology-Based Strategy to Uncover the Mechanism of Zuogui Jiangtang Shuxin Formula in Diabetic Cardiomyopathy

Purpose

This study aimed to explore the mechanism of Zuogui Jiangtang Shuxin formula (ZGJTSXF) in the treatment of diabetic cardiomyopathy (DCM) by an integrative strategy combining serum pharmacochemistry, network pharmacology analysis, and experimental validation.

Methods

An Ultra high performance liquid chromatography-high resolution mass spectrometry (UPLC-Q-Exactive-Orbitrap-MS) method was constructed to identify compounds in rat serum after oral administration of ZGJTSXF. A component-target network between the targets of ZGJTSXF ingredients and DCM was established using Cytoscape. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses were performed to deduce ZGJTSXF-associated targets and pathways. The DCM model mice were treated with ZGJTSXF, and the predicted important signaling pathways were verified using quantitative PCR and Western blot.

Results

We identified 78 compounds in serum of medicated rats, which mainly included flavonoids, small peptides, nucleosides, organic acids, phenylpropanoids, alkaloids, phenanthrenequinones, iridoids, phenols, and saponins. Network pharmacology analysis revealed that ZGJTSXF may regulate targets including ALB, TNF, AKT1, GAPDH, VEGFA, EGFR, SRC, CASP3, MAPK3, JUN, and PI3K/AKT signaling pathway in the treatment of DCM. ZGJTSXF administration improved blood sugar levels, heart function, and cardiac morphological changes in DCM mice. Notably, ZGJTSXF inhibited cardiomyocytes apoptosis, which was associated with restored PI3K/Akt signaling and upregulated Bcl-2 and Bcl-xL proteins expression.

Conclusion

Our preliminary results proposed the material basis and possible mechanisms of ZGJTSXF in treating DCM, which is related to the activation of the PI3K/AKT signaling pathway and apoptosis inhibition. These findings shed new light in developing ZGJTSXF-based therapeutics in treating DCM.

Hydrogen sulfide plays an important role by regulating endoplasmic reticulum stress in myocardial diseases

Endoplasmic reticulum (ER) is an important organelle for protein translation, folding and translocation, as well as the post-translational modification and assembly of newly synthesized secreted proteins. When the excessive accumulation of misfolded and/or unfolded proteins exceeds the processing capacity of ER, ER stress is triggered. The integrated intracellular signal cascade, namely the unfolded protein response, is induced to avoid ER stress. ER stress is involved in many pathological and physiological processes including myocardial diseases. For a long time, hydrogen sulfide (H₂S) has been considered as a toxic gas with the smell of rotten eggs. However, more and more evidences indicate that H₂S is an important gas signal molecule after nitric oxide and carbon monoxide, and regulates a variety of physiological and pathological processes in mammals. In recent years, increasing studies have focused on the regulatory effects of H₂S on ER stress in myocardial diseases, however, the mechanism is not very clear. Therefore, this review focuses on the role of H₂S regulation of ER stress in myocardial diseases, and deeply analyzes the relevant mechanisms so as to lay the foundation for the future researches.

Signaling Pathways Related to Oxidative Stress in Diabetic Cardiomyopathy

Diabetes is a chronic metabolic disease that is increasing in prevalence and causes many complications. Diabetic cardiomyopathy (DCM) is a complication of diabetes that is associated with high mortality, but it is not well defined. Nevertheless, it is generally accepted that DCM refers to a clinical disease that occurs in patients with diabetes and involves ventricular dysfunction, in the absence of other cardiovascular diseases, such as coronary atherosclerotic heart disease, hypertension, or valvular heart disease. However, it is currently uncertain whether the pathogenesis of DCM is directly attributable to metabolic dysfunction or secondary to diabetic microangiopathy. Oxidative stress (OS) is considered to be a key component of its pathogenesis. The production of reactive oxygen species (ROS) in cardiomyocytes is a vicious circle, resulting in further production of ROS, mitochondrial DNA damage, lipid peroxidation, and the post-translational modification of proteins, as well as inflammation, cardiac hypertrophy and fibrosis, ultimately leading to cell death and cardiac dysfunction. ROS have been shown to affect various signaling pathways involved in the development of DCM. For instance, OS causes metabolic disorders by affecting the regulation of PPARα, AMPK/mTOR, and SIRT3/FOXO3a. Furthermore, OS participates in inflammation mediated by the NF-κB pathway, NLRP3 inflammasome, and the TLR4 pathway. OS also promotes TGF-β-, Rho-ROCK-, and Notch-mediated cardiac remodeling, and is involved in the regulation of calcium homeostasis, which impairs ATP production and causes ROS overproduction. In this review, we summarize the signaling pathways that link OS to DCM, with the intention of identifying appropriate targets and new antioxidant therapies for DCM.