Subclassification of dilated cardiomyopathy and interferon treatment

Emerging pharmacologic targets and treatments for myocarditis

Myocarditis is a heterogeneous group of disorders defined by inflammation of the heart muscle. The primary clinical manifestations of myocarditis are heart failure and sudden death in children and young adults. Numerous interventions have been investigated for the treatment of myocarditis, including broad spectrum alteration of the immune response and antiviral treatments; however, success has been limited. Since the myocarditis treatment trials in the 1990s there has been an improved understanding of disease progression and new facets of the immune response have been discovered. This new information provides fresh opportunities to develop therapeutics to treat myocarditis. This review analyzes previous pharmacologic approaches including immunosuppression, high dose intravenous immunoglobulin treatment, immunoadsorption and antiviral treatments, and looks forward toward recently identified immune factors that can be exploited as targets for new treatments. Such strategies include bolstering beneficial regulatory T cells or mitigating the detrimental Th17 T cells which can drive autoimmunity in the heart. The surging interest of the application of humanized monoclonal antibodies makes targeting deleterious arms of the immune response like Th17 cells a tangible goal in the near future. Promising constituents of herbal remedies have also been identified that may hold potential as new pharmacological treatments for myocarditis, however, significant work remains to elucidate the pharmacokinetics and side-effects of these compounds. Finally, advances in our understanding of the function of Matrix Metalloproteinases yield another target for altering disease progression given their role in the development of fibrosis during Dilated Cardiomyopathy. In bringing to light the various new targets and treatments available since the last myocarditis treatment trials, the aim of this review is to explore the new treatments that are possible in new myocarditis treatment trials.

Beta interferon regulation of glucose metabolism is PI3K/Akt dependent and important for antiviral activity against coxsackievirus B3

An effective type I interferon (IFN)-mediated immune response requires the rapid expression of antiviral proteins that are necessary to inhibit viral replication and virus spread. We provide evidence that IFN-β regulates metabolic events important for the induction of a rapid antiviral response: IFN-β decreases the phosphorylation of AMP-activated protein kinase (AMPK), coincident with an increase in intracellular ATP. Our studies reveal a biphasic IFN-β-inducible uptake of glucose by cells, mediated by phosphatidylinositol 3-kinase (PI3K)/Akt, and IFN-β-inducible regulation of GLUT4 translocation to the cell surface. Additionally, we provide evidence that IFN-β-regulated glycolytic metabolism is important for the acute induction of an antiviral response during infection with coxsackievirus B3 (CVB3). Last, we demonstrate that the antidiabetic drug metformin enhances the antiviral potency of IFN-β against CVB3 both in vitro and in vivo. Taken together, these findings highlight an important role for IFN-β in modulating glucose metabolism during a virus infection and suggest that the use of metformin in combination with IFN-β during acute virus infection may result in enhanced antiviral responses.

IMPORTANCE

Type I interferons (IFN) are critical effectors of an antiviral response. These studies describe for the first time a role for IFN-β in regulating metabolism--glucose uptake and ATP production--to meet the energy requirements of a robust cellular antiviral response. Our data suggest that IFN-β regulates glucose metabolism mediated by signaling effectors similarly to activation by insulin. Interference with IFN-β-inducible glucose metabolism diminishes the antiviral response, whereas treatment with metformin, a drug that increases insulin sensitivity, enhances the antiviral potency of IFN-β.

Virus detection and semiquantitation in explanted heart tissues of idiopathic dilated cardiomyopathy adult patients by use of PCR coupled with mass spectrometry analysis

Viral detection in heart tissues has become a central issue for the diagnosis and exploration of the pathogenesis of idiopathic dilated cardiomyopathy (IDCM). In the present study, common cardiotropic viruses in 67 explanted heart samples of 31 IDCM adult patients were detected and semiquantified by using for the first time a new technology based on PCR assay coupled to electrospray ionization-time of flight mass spectrometry analysis (PCR-MS), with comparison to reference quantitative real-time PCR (RT-qPCR) assay. PCR-MS identified single or mixed enterovirus (EV) and parvovirus B19 (PVB19) infections in 27 (40.2%) of 67 samples, corresponding to 15 (48.3%) of the 31 patients, whereas RT-qPCR identified viral infections in 26 (38.8%) samples, corresponding to 16 (51.6%) of the patients. The PCR-MS results correlated well with EV and PVB19 detection by RT-qPCR (kappa = 0.85 [95% confidence interval {CI}, 0.72 to 1.00] and kappa = 0.82 [95% CI, 0.66 to 0.99], respectively). The levels of EV RNA (median, 550 [range, 178 to 3,200] copies/μg of total extracted nucleic acids) and of PVB19 DNA (median, 486 [range, 80 to 1,157] copies/μg of total extracted nucleic acids) were measured using PCR-MS and correlated with those obtained by RT-qPCR (r(2) = 0.57, P = 0.002 and r(2) = 0.64, P < 0.001 for EV and PVB19, respectively). No viruses other than EV and PVB19 strains were detected using the new PCR-MS technology, which is capable of simultaneously identifying 84 known human viruses in one assay. In conclusion, we identified single or mixed EV and PVB19 cardiac infections as potential causes of IDCM. The PCR-MS analysis appeared to be a valuable tool to rapidly detect and semiquantify common viruses in cardiac tissues and may be of major interest to better understand the role of viruses in unexplained cardiomyopathies.

Virus Infection of the Heart – Unmet Therapeutic Needs

For over 50 years, viral infection has been recognized as an important trigger of acute myocarditis, inflammatory dilated cardiomyopathy (DCM) and congestive heart failure. Nevertheless, viral heart disease remains challenging to diagnose and treat. Improved diagnostic methods for myocarditis have led to a better understanding of its pathophysiology. The recognition of virus-mediated damage, inflammation and autoimmune dysregulation in these patients highlights the importance of differentiating between virus-positive and virus-negative inflammatory DCM. These insights have led to the development of novel treatment strategies, including intravenous immunoglobulin and interferon therapy for virus-positive patients. This article will focus on the pathogenesis of viral myocarditis, especially parvovirus B19-induced, its progression to inflammatory DCM and future treatment strategies.

IFN-alpha expression and antiviral effects are subtype and cell type specific in the cardiac response to viral infection

The interferon-beta (IFN-beta) response is critical for protection against viral myocarditis in several mouse models, and IFN-alpha or -beta treatment is beneficial against human viral myocarditis. The IFN-beta response in cardiac myocytes and cardiac fibroblasts forms an integrated network for organ protection; however, the different IFN-alpha subtypes have not been studied in cardiac cells. We developed a quantitative RT-PCR assay that distinguishes between 13 highly conserved IFN-alpha subtypes and found that reovirus T3D induces five IFN-alpha subtypes in primary cardiac myocyte and fibroblast cultures: IFN-alpha1, -alpha2, -alpha4, -alpha5, and -alpha8/6. Murine IFN-alpha1, -alpha2, -alpha4, or -alpha5 treatment induced IRF7 and ISG56 and inhibited reovirus T3D replication in both cell types. This first investigation of IFN-alpha subtypes in cardiac cells for any virus demonstrates that IFN-alpha is induced in cardiac cells, that it is both subtype and cell type specific, and that it is likely important in the antiviral cardiac response.

Viral myocarditis: diagnosis, aetiology and management

Myocarditis is an inflammatory disease of the cardiac muscle caused by myocardial infiltration of immunocompetent cells following any kind of cardiac injury. Classic myocarditis mainly occurs as a result of the host's immune response against organisms that cause common infectious illnesses, as a manifestation of hypersensitivity or as a toxic reaction to drug therapy. Chronic inflammatory events may survive successful clearance of initial cardiotoxic agents, be triggered or amplified by autoimmunological processes, or develop in the context of systemic diseases. If the underlying infectious or immune-mediated causes of the disease are carefully defined by clinical and biopsy-based tools, specific immunosuppressive and antiviral treatment options may improve the prognosis of patients with acute and chronic disease.

Autoimmunological features in inflammatory cardiomyopathy

During recent years, increasing evidence has been obtained that cellular as well as humoral autoimmunity is involved in the pathogenesis of dilated cardiomyopathy (DCM). The immune system is generally activated by viral infections with the objective of virus elimination from the myocardium. However, a relevant number of patients demonstrate viral persistence and/or chronic inflammation in the myocardium. This chronic myocardial inflammation, defined by chronic inflammation, is termed "inflammatory cardiomyopathy" according to the WHO classification of cardiomyopathies. Chronic inflammation is frequently followed by the development of autoimmunity. A breakdown in the control mechanisms protecting against autoimmune reactions by both presentation of normally not accessible self-antigens and bystander- activation, induced by the pathogen, leads to the formation of autoreactive antibodies and T cells. The auto-reactive antibodies interact directly with heart tissue resulting in altered signal transduction or complement activation, whereas the T cell-mediated mechanisms include direct attack by cytotoxic T cells or indirect effects of cytotoxic cytokines released by stimulated T cells or macrophages.

Anti-viral treatment in patients with virus-induced cardiomyopathy

Ongoing viral persistence in the myocardium is associated with an adverse prognosis of cardiomyopathy eventually resulting in a reduced capacity for work and thus it is associated with enormous social costs. Experimental and clinical data highlight that an imbalance of the cytokine network and a defect in the cytokine-induced immune response may constitute major causes leading to the development of virus persistence and progression of myocardial dysfunction. Reversibility of cardiac impairment during the early stages of the disease and the arising chance of specific treatment options demand early diagnosis and treatment of the disease. Our pilot data on anti-viral treatment using INF-beta showed beneficial clinical effects and suggest that some of the ventricular dysfunction and wall motion abnormalities resolved after elimination of the responsible agents. The data also suggest that elimination of cardiotropic viruses and associated clinical effects may occur even in DCM patients presenting with a long history.

Basal and reovirus-induced beta interferon (IFN-beta) and IFN-beta-stimulated gene expression are cell type specific in the cardiac protective response

Viral myocarditis is an important human disease, with a wide variety of viruses implicated. Cardiac myocytes are not replenished yet are critical for host survival and thus may have a unique response to infection. Previously, we determined that the extent of reovirus induction of beta interferon (IFN-beta) and IFN-beta-mediated protection in primary cardiac myocyte cultures was inversely correlated with the extent of reovirus-induced cardiac damage in a mouse model. Surprisingly, and in contrast, the IFN-beta response did not determine reovirus replication in skeletal muscle cells. Here we compared the IFN-beta response in cardiac myocytes to that in primary cardiac fibroblast cultures, a readily replenished cardiac cell type. We compared basal and reovirus-induced expression of IFN-beta, IRF-7 (an interferon-stimulated gene [ISG] that further induces IFN-beta), and another ISG (561) in the two cell types by using real-time reverse transcription-PCR. Basal IFN-beta, IRF-7, and 561 expression was higher in cardiac myocytes than in cardiac fibroblasts. Reovirus T3D induced greater expression of IFN-beta in cardiac myocytes than in cardiac fibroblasts but equivalent expression of IRF-7 and 561 in the two cell types (though fold induction for IRF-7 and 561 was higher in fibroblasts than in myocytes because of the differences in basal expression). Interestingly, while reovirus replicated to equivalent titers in cardiac myocytes and cardiac fibroblasts, removal of IFN-beta resulted in 10-fold-greater reovirus replication in the fibroblasts than in the myocytes. Together the data suggest that the IFN-beta response controls reovirus replication equivalently in the two cell types. In the absence of reovirus-induced IFN-beta, however, reovirus replicates to higher titers in cardiac fibroblasts than in cardiac myocytes, suggesting that the higher basal IFN-beta and ISG expression in myocytes may play an important protective role.

High prevalence of viral genomes and multiple viral infections in the myocardium of adults with "idiopathic" left ventricular dysfunction

BACKGROUND

For a long time, enteroviruses have been considered to be the most common cause of acute viral myocarditis (MC), with possible transition from MC to dilated cardiomyopathy (DCM). Recent investigations have shown, however, that other viruses are also frequently encountered in MC patients, suggesting that persistence of various virus species may play a pathogenic role in the transition from MC to DCM. The purpose of this study was to screen endomyocardial biopsies (EMBs) from patients with "idiopathic" DCM for the presence of viral genomes by using polymerase chain reaction (PCR) to assess the frequency of cardiac viral infections that may be involved in the pathogenesis of the disease.

METHODS AND RESULTS

EMBs were obtained for PCR analysis from 245 consecutive patients (median left ventricular ejection fraction, 35.0%; range, 9% to 59%). PCR and reverse transcription-PCR were performed to detect the genomic sequences of enterovirus (EV), adenovirus (ADV), human cytomegalovirus (HCMV), herpes simplex virus, Epstein-Barr virus (EBV), human herpesvirus 6 (HHV-6), parvovirus B19 (PVB19), and influenza A and B viruses. Myocardial inflammation was assessed by histological and immunohistological analyses. Viral genomes could be amplified from EMBs of 165 (67.4%) of the 245 DCM patients: EV=23 (9.4%), ADV=4 (1.6%), PVB19=126 (51.4%), HHV-6=53 (21.6%), EBV=5 (2.0%), HCMV=2 (0.8%), including n=45 cases (27.3%) with multiple infections. Active or borderline myocarditis according to the Dallas classification did not exist in any case. Lymphocyte and macrophage infiltrates were not significantly different in virus-positive versus virus-negative patients.

CONCLUSIONS

Viral genomes were frequently detected in EMBs of patients with systolic left ventricular dysfunction. Our data suggest that myocardial persistence of various viruses, often presenting as multiple infections, may play a role in the pathogenesis of DCM far more frequently than suspected so far.

PKR's protective role in viral myocarditis

Reovirus-induced murine myocarditis provides an excellent model for the human disease. Previously, we showed that reovirus induction of and sensitivity to interferon-beta (IFN-beta) are important determinants of protection against cardiac damage. IFN-beta induces a number of genes with antiviral activities, including the dsRNA-activated protein kinase, PKR. Once bound to viral dsRNA, PKR becomes activated and phosphorylates eukaryotic initiation factor-2 alpha (eIF2 alpha) leading to the cessation of host cell translation. Additionally, activated PKR can exert its antiviral effects by inducing phosphorylation of I kappa B, leading to the activation of the transcription factor NF kappa B and subsequent induction of IFN-beta. Thus, activated PKR can both induce and be induced by IFN-beta. Recently, numerous reports have shown PKR to be dispensable for both induction of IFN as well as protection against disease. However, both PKR's role in the heart in response to viral infection and its ability to prevent cardiac damage have gone largely unexplored. Here, we demonstrate PKR to be critical for viral induction of IFN-beta in primary cardiac myocyte cultures. Additionally, we show that loss of PKR leads to an increase in virulence for both myocarditic and nonmyocarditic reoviruses. Finally, we demonstrate PKR to be critical for protection against reovirus-induced viral myocarditis.

Interferons in enteroviral heart disease: modulation of cytokine expression and antiviral activity

Interferon (IFN)-beta has a more than 120-fold higher antiviral activity than the closely related IFN-alpha in human myocardial fibroblasts infected with the cardiotropic enterovirus coxsackievirus B3 (CVB3). CVB3 replication induces interleukin (IL)-6 and IL-8 expression in myocardial fibroblasts, and suppresses the expression of monocyte chemoattractant protein-1 (MCP-1). We investigated whether the higher antiviral activity of IFN-beta compared to IFN-alpha was a result of a suppression of IL-8 expression by IFN-beta since previous studies had indicated that IL-8 stimulates enterovirus replication. Human myocardial fibroblasts were treated with either IFN-alpha, IFN-beta or IFN-gamma (0, 10, 100, or 1,000 IU/ml) and the concentrations of IL-6, IL-8 and MCP-1 were measured in culture supernatants by immunoassays. Both IFN-beta and IFN-gamma reduced IL-6 and IL-8 expression significantly. In addition, neutralization of IL-8 in culture supernatants of myocardial fibroblasts using a monoclonal antibody demonstrated a significant reduction of CVB3 titers. Antiproliferative effects of all three IFNs were very low (<30% with 1,000 IU/ml), indicating that the suppression IL-6 and IL-8 was not related to cytotoxicity. MCP-1 expression was increased only by high concentrations of IFN-gamma (1,000 IU/ml). By contrast, IFN-alpha had no significant effect on IL-6, IL-8 and MCP-1 expression. In conclusion, suppression of IL-8 expression is an "immuno-modulating" feature of IFN-beta in human myocardial fibroblasts, which is similar to the activity of IFN-gamma. This feature of IFN-beta contributes to its high antiviral activity against CVB3 and may be useful in the treatment of enteroviral heart disease.

Successful treatment of enterovirus-induced myocarditis with interferon-alpha

No randomized, placebo-controlled studies have investigated interferon-alpha therapy in enterovirus-proven myocarditis. This report describes 2 patients with enterovirus-induced myocarditis (1 with associated Churg-Strauss syndrome) who at follow-up endomyocardial biopsy showed clinical and hemodynamic improvement and viral clearance (using polymerase chain reaction) after interferon-alpha therapy.

Myocarditis

Myocarditis and its sequela, dilated cardiomyopathy (DCM), cause substantial morbidity and mortality, especially in children and young adults. Physicians should include myocarditis in the differential diagnosis of all patients who have new symptoms of heart failure, arrhythmia, or chest pain syndromes of unclear cause, and should strongly consider performing endomyocardial biopsy (EMB) to establish the diagnosis. It may be necessary to perform multiple or serial biopsies to increase sensitivity. Patients with myocarditis and symptomatic heart failure, chest pain, or arrhythmias need hospitalization for evaluation and treatment. Patients with symptomatic left ventricular dysfunction should be treated with conventional heart failure therapy, including angiotensin-converting enzyme (ACE) inhibitors, digitalis, diuretics, and beta-blockers. Patients with arrhythmias or syncope may require electrophysiologic evaluation. In addition to conventional therapy, physicians should consider a course of immunosuppressive therapy in selected patients. The clinical course, response to therapy, and left ventricular function need close monitoring. Patients with myocarditis and rapidly progressive heart failure or cardiogenic shock should be referred early to an advanced heart failure center for implantation of a ventricular assist device and consideration for cardiac transplantation.

Myocarditis

Myocarditis and its sequela, dilated cardiomyopathy (DCM), cause substantial morbidity and mortality, especially in children and young adults. Physicians should include myocarditis in the differential diagnosis of all patients who have new symptoms of heart failure, arrhythmia, or chest pain syndromes of unclear cause, and should strongly consider performing endomyocardial biopsy (EMB) to establish the diagnosis. It may be necessary to perform multiple or serial biopsies to increase sensitivity. Patients with myocarditis and symptomatic heart failure, chest pain, or arrhythmias need hospitalization for evaluation and treatment. Patients with symptomatic left ventricular dysfunction should be treated with conventional heart failure therapy, including angiotensin-converting enzyme (ACE) inhibitors, digitalis, diuretics, and beta-blockers. Patients with arrhythmias or syncope may require electrophysiologic evaluation. In addition to conventional therapy, physicians should consider a course of immunosuppressive therapy in selected patients. The clinical course, response to therapy, and left ventricular function need close monitoring. Patients with myocarditis and rapidly progressive heart failure or cardiogenic shock should be referred early to an advanced heart failure center for implantation of a ventricular assist device and consideration for cardiac transplantation.

Interferon regulatory factor 3 is required for viral induction of beta interferon in primary cardiac myocyte cultures

Viral myocarditis affects an estimated 5 to 20% of the human population. The antiviral cytokine beta interferon (IFN-beta) is critical for protection against viral myocarditis in mice. That is, nonmyocarditic reoviruses induce myocarditis in mice that lack IFN-alpha/beta, and nonmyocarditic reoviruses both induce more IFN-beta and are more sensitive to the antiviral effects of IFN-beta than myocarditic reoviruses in primary cardiac myocyte cultures. Induction of IFN-beta in certain cell types involves viral activation of the transcription factor interferon regulatory factor 3 (IRF-3). To address whether IRF-3 can induce IFN-beta in cardiac myocytes, primary cardiac myocyte cultures and control L929 cells were transfected with a plasmid constitutively expressing IRF-3. Overexpression of IRF-3 resulted in induction of IFN-beta in the absence of viral infection in both cell types. To address whether IRF-3 is required for viral induction of IFN-beta, cell cultures were transfected with a plasmid constitutively expressing a dominant negative IRF-3 protein. The dominant negative IRF-3 reduced reovirus induction of IFN-beta in control L929 cells and completely eliminated induction in primary cardiac myocyte cultures. This provides the first identification of a cardiac cellular factor required for viral induction of IFN-beta and the first report of any cell type requiring IRF-3 for this response.

[Therapy of dilated cardiomyopathies with and without inflammation]

Diagnosis of inflammatory dilated cardiomyopathy relies on the histological and immunohistological examination of endomyocardial biopsies. Only with the demonstration of the etiological agents in the myocardium specific therapy can be attempted. Whereas the spontaneous course of endemic myocarditis with little hemodynamic impairment is fair, the prognosis of symptomatic myocarditis and dilated cardiomyopathy is poor, with complete restitution in 35% and a 10-year survival rate of 30%. Restriction of physical activity is a validated form of therapy with normalization of the heart size in 40 to 60%. Symptomatic medical therapy consists of digitalis, diuretics, ACE-inhibitors and vasodilators and betablocker therapy, where a reduction of mortality was demonstrated in clinical (sub)studies up to 60%. Specific forms of therapy in inflammatory cardiomyopathy rely on the demonstration or lack of viral persistence or signs of autoreactivity in the myocardial tissue. Immunosuppressive therapy in autoimmune forms improved cardiac function in up to 60% of the patients in controlled trials, when compared to controls (40%). The double-blind randomized myocarditis treatment trial, which unfortunately did not distinguish viral from autoimmune myocarditis could not demonstrate such a benefit, however. Depending on the etiology of the disease, immunomodulation with immunoglobulins or interferon or antiviral therapy with hyperimmunoglobulins are presently tested in clinical treatment trials (ESETCID) in patients with enterovirus-positive or cytomegalovirus-positive and adenovirus-positive chronic myocarditis. Specific therapies are aimed to avoid the progression of the disease which may ultimately lead to heart failure with a cardiac assist device or heart transplantation as ultimate therapeutic option.

Effects of intranasal administration of recombinant murine interferon-gamma on murine acute myocarditis caused by encephalomyocarditis virus

BACKGROUND

Viral myocarditis has been strongly implicated in the pathogenesis of dilated cardiomyopathy as well as acute myocarditis. Among the antiviral therapies, interferons (IFNs) have been widely studied and become very important in clinical practice.

METHODS AND RESULTS

To investigate the possibilities of IFN therapy in viral myocarditis, we analyzed the effects of recombinant murine interferon (mIFN)-gamma and natural mIFN-alpha/beta by the intranasal and intramuscular routes on the development of acute murine myocarditis caused by encephalomyocarditis virus. Both mIFN-gamma and mIFN-alpha/beta treatment by either route significantly increased the survival rate; none of the mIFN-gamma-treated mice died. The effect of mIFN-gamma was significantly greater than that of mIFN-alpha/beta. Furthermore, intranasal administration of mIFN-gamma significantly suppressed virus replication and inflammation in the heart.

CONCLUSIONS

Our data demonstrate that IFN therapy, especially intranasal administration of IFN-gamma, dramatically improved the prognosis of acute murine viral myocarditis by suppressing virus replication and raises the possibility of antiviral therapy with IFN-gamma in patients with acute myocarditis.

Monocyte activation in congestive heart failure due to coronary artery disease and idiopathic dilated cardiomyopathy

OBJECTIVE

To investigate plasma tumor necrosis factor (TNF)alpha, tumor necrosis factor alpha soluble receptor I, interleukin-1beta and neopterin concentrations as markers of monocyte activation in patients with heart failure.

STUDY DESIGN

The group consisted of patients with heart failure due to dilated cardiomyopathy (n=19) and coronary artery disease (n=11). Patients without cardiac failure served as controls (n=10).

RESULTS

TNFalpha concentrations were elevated only in heart failure patients with coronary artery disease (2.9+/-0.3 pg/ml versus 1.7+/-0.3 pg/ml; P<0.05). When the patients were grouped according to acute and chronic failure, TNFalpha concentrations were significantly elevated in acute failure (3.1+/-0.4 pg/ml, n=6 versus 1.7+/-0.2 pg/ml, n=8; P<0.05). TNFalpha concentrations were elevated in patients with coronary artery disease and chronic heart failure compared to coronary artery disease patients without failure (2.0+/-0.4 pg/ml, n=6 versus 1.8+/-0.3 pg/ml, n=7; P<0.05). A higher proportion of patients with myocardial insufficiency showed increased lipopolysaccharide-inducible TNFalpha concentrations (10/30 versus 0/9, P<0.05).

CONCLUSIONS

TNFalpha is elevated in patients with acute cardiac decompensation. Among patients with chronic heart failure only those with coronary artery disease exhibit increased levels. Cytokine concentrations are similar in heart failure due to dilated cardiomyopathy and coronary artery disease. Monocytes of patients suffering from cardiac insufficiency show an increased sensitivity towards stimuli such as lipopolysaccharides.