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Nandi SS, Katsurada K, Moulton MJ, Zheng H, Patel KP. Enhanced central sympathetic tone induces heart failure with preserved ejection fraction (HFpEF) in rats. Front Physiol 2023; 14:1277065. [PMID: 38169715 PMCID: PMC10758618 DOI: 10.3389/fphys.2023.1277065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 11/20/2023] [Indexed: 01/05/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a heterogenous clinical syndrome characterized by diastolic dysfunction, concentric cardiac left ventricular (LV) hypertrophy, and myocardial fibrosis with preserved systolic function. However, the underlying mechanisms of HFpEF are not clear. We hypothesize that an enhanced central sympathetic drive is sufficient to induce LV dysfunction and HFpEF in rats. Male Sprague-Dawley rats were subjected to central infusion of either saline controls (saline) or angiotensin II (Ang II, 20 ng/min, i.c.v) via osmotic mini-pumps for 14 days to elicit enhanced sympathetic drive. Echocardiography and invasive cardiac catheterization were used to measure systolic and diastolic functions. Mean arterial pressure, heart rate, left ventricular end-diastolic pressure (LVEDP), and ± dP/dt changes in responses to isoproterenol (0.5 μg/kg, iv) were measured. Central infusion of Ang II resulted in increased sympatho-excitation with a consequent increase in blood pressure. Although the ejection fraction was comparable between the groups, there was a decrease in the E/A ratio (saline: 1.5 ± 0.2 vs Ang II: 1.2 ± 0.1). LVEDP was significantly increased in the Ang II-treated group (saline: 1.8 ± 0.2 vs Ang II: 4.6 ± 0.5). The increase in +dP/dt to isoproterenol was not significantly different between the groups, but the response in -dP/dt was significantly lower in Ang II-infused rats (saline: 11,765 ± 708 mmHg/s vs Ang II: 8,581 ± 661). Ang II-infused rats demonstrated an increased heart to body weight ratio, cardiomyocyte hypertrophy, and fibrosis. There were elevated levels of atrial natriuretic peptide and interleukin-6 in the Ang II-infused group. In conclusion, central infusion of Ang II in rats induces sympatho-excitation with concurrent diastolic dysfunction, pathological cardiac concentric hypertrophy, and cardiac fibrosis. This novel model of centrally mediated sympatho-excitation demonstrates characteristic diastolic dysfunction in rats, representing a potentially useful preclinical murine model of HFpEF to investigate various altered underlying mechanisms during HFpEF in future studies.
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Affiliation(s)
- Shyam S. Nandi
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE, United States
| | - Kenichi Katsurada
- Division of Cardiovascular Medicine, Department of Internal Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Michael J. Moulton
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, United States
| | - Hong Zheng
- Basic Biomedical Sciences, Sanford School of Medicine, University of South Dakota, Vermillion, SD, United States
| | - Kaushik P. Patel
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE, United States
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Jasińska-Stroschein M. Searching for Effective Treatments in HFpEF: Implications for Modeling the Disease in Rodents. Pharmaceuticals (Basel) 2023; 16:1449. [PMID: 37895920 PMCID: PMC10610318 DOI: 10.3390/ph16101449] [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: 09/10/2023] [Revised: 10/04/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND While the prevalence of heart failure with preserved ejection fraction (HFpEF) has increased over the last two decades, there still remains a lack of effective treatment. A key therapeutic challenge is posed by the absence of animal models that accurately replicate the complexities of HFpEF. The present review summarizes the effects of a wide spectrum of therapeutic agents on HF. METHODS Two online databases were searched for studies; in total, 194 experimental protocols were analyzed following the PRISMA protocol. RESULTS A diverse range of models has been proposed for studying therapeutic interventions for HFpEF, with most being based on pressure overload and systemic hypertension. They have been used to evaluate more than 150 different substances including ARNIs, ARBs, HMGR inhibitors, SGLT-2 inhibitors and incretins. Existing preclinical studies have primarily focused on LV diastolic performance, and this has been significantly improved by a wide spectrum of candidate therapeutic agents. Few experiments have investigated the normalization of pulmonary congestion, exercise capacity, animal mortality, or certain molecular hallmarks of heart disease. CONCLUSIONS The development of comprehensive preclinical HFpEF models, with multi-organ system phenotyping and physiologic stress-based functional testing, is needed for more successful translation of preclinical research to clinical trials.
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Garg P, Javed W, Assadi H, Alabed S, Grafton-Clarke C, Swift AJ, Williams G, Al-Mohammad A, Sawh C, Vassiliou VS, Khanji MY, Ricci F, Greenwood JP, Plein S, Swoboda P. An acute increase in Left Atrial volume and left ventricular filling pressure during Adenosine administered myocardial hyperaemia: CMR First-Pass Perfusion Study. BMC Cardiovasc Disord 2023; 23:246. [PMID: 37170253 PMCID: PMC10176699 DOI: 10.1186/s12872-023-03230-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/07/2023] [Indexed: 05/13/2023] Open
Abstract
OBJECTIVE To investigate whether left atrial (LA) volume and left ventricular filling pressure (LVFP) assessed by cardiovascular magnetic resonance (CMR) change during adenosine delivered myocardial hyperaemia as part of a first-pass stress perfusion study. METHODS AND RESULTS We enrolled 33 patients who had stress CMR. These patients had a baseline four-chamber cine and stress four-chamber cine, which was done at peak myocardial hyperaemic state after administering adenosine. The left and right atria were segmented in the end ventricular diastolic and systolic phases. Short-axis cine stack was segmented for ventricular functional assessment. At peak hyperaemic state, left atrial end ventricular systolic volume just before mitral valve opening increased significantly from baseline in all (91 ± 35ml vs. 81 ± 33ml, P = 0.0002), in males only (99 ± 35ml vs. 88 ± 33ml, P = 0.002) and females only (70 ± 26ml vs. 62 ± 22ml, P = 0.02). The right atrial end ventricular systolic volume increased less significantly from baseline (68 ± 21ml vs. 63 ± 20ml, P = 0.0448). CMR-derived LVFP (equivalent to pulmonary capillary wedge pressure) increased significantly at the peak hyperaemic state in all (15.1 ± 2.9mmHg vs. 14.4 ± 2.8mmHg, P = 0.0002), females only (12.9 ± 2.1mmHg vs. 12.3 ± 1.9mmHg, P = 0.029) and males only (15.9 ± 2.8mmHg vs. 15.2 ± 2.7mmHg, P = 0.002) cohorts. CONCLUSION Left atrial volume assessment by CMR can measure acute and dynamic changes in preloading conditions on the left ventricle. During adenosine administered first-pass perfusion CMR, left atrial volume and LVFP rise significantly.
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Affiliation(s)
- Pankaj Garg
- University of East Anglia, Norwich Medical School, Norwich, Norfolk, UK.
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK.
- Department of Infection, Immunity and Cardiovascular disease, University of Sheffield Medical School and Sheffield Teaching Hospitals NHS Trust, Sheffield, UK.
- Norwich Medical School, Norwich Research Park, Norwich, NR4 7UQ, UK.
| | - Wasim Javed
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Hosamadin Assadi
- University of East Anglia, Norwich Medical School, Norwich, Norfolk, UK
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular disease, University of Sheffield Medical School and Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Ciaran Grafton-Clarke
- University of East Anglia, Norwich Medical School, Norwich, Norfolk, UK
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Andrew J Swift
- Department of Infection, Immunity and Cardiovascular disease, University of Sheffield Medical School and Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Gareth Williams
- Department of Infection, Immunity and Cardiovascular disease, University of Sheffield Medical School and Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Abdallah Al-Mohammad
- Department of Infection, Immunity and Cardiovascular disease, University of Sheffield Medical School and Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Chris Sawh
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Vassilios S Vassiliou
- University of East Anglia, Norwich Medical School, Norwich, Norfolk, UK
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Mohammed Y Khanji
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - John P Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Sven Plein
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Peter Swoboda
- Norwich Medical School, Norwich Research Park, Norwich, NR4 7UQ, UK
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Zabielska-Kaczorowska MA, Braczko A, Pelikant-Malecka I, Slominska EM, Smolenski RT. Hidden Pool of Cardiac Adenine Nucleotides That Controls Adenosine Production. Pharmaceuticals (Basel) 2023; 16:ph16040599. [PMID: 37111356 PMCID: PMC10142527 DOI: 10.3390/ph16040599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
Myocardial ischemic adenosine production decreases in subsequent events that may blunt its protective functions. To test the relation between total or mitochondrial cardiac adenine nucleotide pool (TAN) on the energy status with adenosine production, Langendorff perfused rat hearts were subjected to three protocols: 1 min ischemia at 40 min, 10 min ischemia at 50 min, and 1 min ischemia at 85 min in Group I; additional infusion of adenosine (30 µM) for 15 min after 10 min ischemia in Group I-Ado, and 1 min ischemia at 40 and 85 min in the controls (Group No I). A 31P NMR and an HPLC were used for the analysis of nucleotide and catabolite concentrations in the heart and coronary effluent. Cardiac adenosine production in Group I measured after 1 min ischemia at 85 min decreased to less than 15% of that at 40 min in Group I, accompanied by a decrease in cardiac ATP and TAN to 65% of the initial results. Adenosine production at 85 min was restored to 45% of that at 40 min in Group I-Ado, accompanied by a rebound of ATP and TAN by 10% vs. Group I. Mitochondrial TAN and free AMP concentrations paralleled that of total cardiac TAN. Changes in energy equilibrium or mitochondrial function were minor. This study highlights that only a fraction of the cardiac adenine nucleotide pool is available for adenosine production, but further studies are necessary to clarify its nature.
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Affiliation(s)
- Magdalena A Zabielska-Kaczorowska
- Department of Physiology, Medical University of Gdansk, 80-210 Gdansk, Poland
- Department of Biochemistry, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Alicja Braczko
- Department of Biochemistry, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Iwona Pelikant-Malecka
- Division of Medical Laboratory Diagnostics, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Ewa M Slominska
- Department of Biochemistry, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Ryszard T Smolenski
- Department of Biochemistry, Medical University of Gdansk, 80-210 Gdansk, Poland
- Heart Science Centre, Imperial College at Harefield Hospital, Harefield UB9 6JH, UK
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Buncha V, Fopiano KA, Lang L, Williams C, Horuzsko A, Filosa JA, Kapuku G, Bagi Z. Mice with endothelial cell-selective adhesion molecule deficiency develop coronary microvascular rarefaction and left ventricle diastolic dysfunction. Physiol Rep 2023; 11:e15643. [PMID: 36946064 PMCID: PMC10031300 DOI: 10.14814/phy2.15643] [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: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/23/2023] Open
Abstract
Endothelial cell-selective adhesion molecule (ESAM) regulates inflammatory cell adhesion and transmigration and promotes angiogenesis. Here, we examined the role of ESAM in cardiac vascularization, inflammatory cell infiltration, and left ventricle (LV) diastolic function under basal and hemodynamic stress conditions. We employed mice with homozygous genetic deletion of ESAM (ESAM-/- ) and also performed uninephrectomy and aldosterone infusion (UNX-Aldo) to induce volume and pressure overload. Using echocardiography, we found that ESAM-/- mice display no change in systolic function. However, they develop LV diastolic dysfunction, as indicated by a significantly reduced E/A ratio (E = early, A = late mitral inflow peak velocities), increased E/e' ratio, isovolumic relaxation time (IVRT), and E wave deceleration time. An unbiased automated tracing and 3D reconstruction of coronary vasculature revealed that ESAM-/- mice had reduced coronary vascular density. Arteries of ESAM-/- mice exhibited impaired endothelial sprouting and in cultured endothelial cells siRNA-mediated ESAM knockdown reduced tube formation. Changes in ESAM-/- mice were accompanied by elevated myocardial inflammatory cytokine and myeloperoxidase-positive neutrophil levels. Furthermore, UNX-Aldo procedure in wild type mice induced LV diastolic dysfunction, which was accompanied by significantly increased serum ESAM levels. When compared to wild types, ESAM-/- mice with UNX-Aldo displayed worsening of LV diastolic function, as indicated by increased IVRT and pulmonary edema. Thus, we propose that ESAM plays a mechanistic role in proper myocardial vascularization and the maintenance of LV diastolic function under basal and hemodynamic stress conditions.
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Affiliation(s)
- Vadym Buncha
- Department of PhysiologyMedical College of Georgia, Augusta UniversityGeorgiaAugustaUSA
| | - Katie Anne Fopiano
- Department of PhysiologyMedical College of Georgia, Augusta UniversityGeorgiaAugustaUSA
| | - Liwei Lang
- Department of PhysiologyMedical College of Georgia, Augusta UniversityGeorgiaAugustaUSA
| | - Celestine Williams
- Department of MedicineGeorgia Prevention Institute, Medical College of Georgia, Augusta UniversityAugustaGeorgiaUSA
| | - Anatolij Horuzsko
- Georgia Cancer CenterMedical College of Georgia, Augusta UniversityGeorgiaAugustaUSA
| | - Jessica Andrea Filosa
- Department of PhysiologyMedical College of Georgia, Augusta UniversityGeorgiaAugustaUSA
| | - Gaston Kapuku
- Department of MedicineGeorgia Prevention Institute, Medical College of Georgia, Augusta UniversityAugustaGeorgiaUSA
| | - Zsolt Bagi
- Department of PhysiologyMedical College of Georgia, Augusta UniversityGeorgiaAugustaUSA
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6
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Balzer C, Cleveland WJ, Li Z, Riess ML. Buffer glucose adjustment affects myocardial function after ischemia-reperfusion in long-term diabetic rat isolated hearts. Physiol Rep 2022; 10:e15387. [PMID: 36324287 PMCID: PMC9630758 DOI: 10.14814/phy2.15387] [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: 03/27/2022] [Revised: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 11/06/2022] Open
Abstract
Due to its comorbidities type 2 diabetes mellitus (T2DM) and hypertension, the Zucker Spontaneous Hypertensive Fatty (ZSF1) rat is a clinically relevant animal model when assessing ischemia-reperfusion (IR) injury. Most IR studies in hearts isolated from diabetic animals have been conducted at normal glucose concentrations, providing a different environment compared to in-vivo. We hypothesized IR injury to be attenuated in isolated hearts of diabetic ZSF1 rats when adjusting the Krebs-buffer (KB) to their in-vivo, i.e., elevated blood glucose (BG) levels. Diabetic and non-diabetic ZSF1 rats were anesthetized, hearts isolated and Langendorff-prepared. While standard KB was used for the non-diabetic and diabetic unadjusted groups, KB with glucose levels increased to each rat's prior BG level was used for the adjusted diabetic group. All hearts underwent 30 min ischemia and 120 min reperfusion. Diastolic contracture during ischemia and early reperfusion was delayed and temporarily attenuated in the adjusted compared to the unadjusted diabetic and the non-diabetic groups. The decrease in coronary flow on reperfusion was attenuated in diabetic animals. Left ventricular developed pressure and contractility were not different among the three groups. Infarct size was significantly lower in non-diabetic animals; buffer adjustment made no difference in diabetic animals. In our study, T2DM did not worsen myocardial function in ZSF1 rat isolated hearts. Since our results reveal that hearts with an adjusted glucose level exhibit an at least temporary improvement of function following IR, further studies should consider adapting glucose levels to create more realistic conditions in isolated, perfused hearts.
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Affiliation(s)
- Claudius Balzer
- Department of AnesthesiologyVanderbilt University Medical CenterNashvilleTennesseeUSA
- Department of AnesthesiologyUniversity Medicine GreifswaldGreifswaldGermany
| | - William J. Cleveland
- Department of AnesthesiologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Zhu Li
- Department of AnesthesiologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Matthias L. Riess
- Department of AnesthesiologyVanderbilt University Medical CenterNashvilleTennesseeUSA
- Department of AnesthesiologyTVHS VA Medical CenterNashvilleTennesseeUSA
- Department of PharmacologyVanderbilt UniversityNashvilleTennesseeUSA
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Wölkart G, Stessel H, Fassett E, Teschl E, Friedl K, Trummer M, Schrammel A, Kollau A, Mayer B, Fassett J. Adenosine kinase (ADK) inhibition with ABT-702 induces ADK protein degradation and a distinct form of sustained cardioprotection. Eur J Pharmacol 2022; 927:175050. [PMID: 35618039 DOI: 10.1016/j.ejphar.2022.175050] [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: 11/19/2021] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 11/18/2022]
Abstract
Pharmacological inhibition of adenosine kinase (ADK), the major route of myocardial adenosine metabolism, can elicit acute cardioprotection against ischemia-reperfusion (IR) by increasing adenosine signaling. Here, we identified a novel, extended effect of the ADK inhibitor, ABT-702, on cardiac ADK protein longevity and investigated its impact on sustained adenosinergic cardioprotection. We found that ABT-702 treatment significantly reduced cardiac ADK protein content in mice 24-72 h after administration (IP or oral). ABT-702 did not alter ADK mRNA levels, but strongly diminished (ADK-L) isoform protein content through a proteasome-dependent mechanism. Langendorff perfusion experiments revealed that hearts from ABT-702-treated mice maintain higher adenosine release long after ABT-702 tissue elimination, accompanied by increased basal coronary flow (CF) and robust tolerance to IR. Sustained cardioprotection by ABT-702 did not involve increased nitric oxide synthase expression, but was completely dependent upon increased adenosine release in the delayed phase (24 h), as indicated by the loss of cardioprotection and CF increase upon perfusion of adenosine deaminase or adenosine receptor antagonist, 8-phenyltheophylline. Importantly, blocking adenosine receptor activity with theophylline during ABT-702 administration prevented ADK degradation, preserved late cardiac ADK activity, diminished CF increase and abolished delayed cardioprotection, indicating that early adenosine receptor signaling induces late ADK degradation to elicit sustained adenosine release. Together, these results indicate that ABT-702 induces a distinct form of delayed cardioprotection mediated by adenosine receptor-dependent, proteasomal degradation of cardiac ADK and enhanced adenosine signaling in the late phase. These findings suggest ADK protein stability may be pharmacologically targeted to achieve sustained adenosinergic cardioprotection.
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Affiliation(s)
- Gerald Wölkart
- Department of Pharmacology and Toxicology, University of Graz, 8010, Graz, Austria
| | - Heike Stessel
- Department of Pharmacology and Toxicology, University of Graz, 8010, Graz, Austria
| | - Erin Fassett
- Department of Pharmacology and Toxicology, University of Graz, 8010, Graz, Austria
| | - Eva Teschl
- Department of Pharmacology and Toxicology, University of Graz, 8010, Graz, Austria
| | - Katrin Friedl
- Department of Pharmacology and Toxicology, University of Graz, 8010, Graz, Austria
| | - Modesta Trummer
- Department of Pharmacology and Toxicology, University of Graz, 8010, Graz, Austria
| | - Astrid Schrammel
- Department of Pharmacology and Toxicology, University of Graz, 8010, Graz, Austria
| | - Alexander Kollau
- Department of Pharmacology and Toxicology, University of Graz, 8010, Graz, Austria
| | - Bernd Mayer
- Department of Pharmacology and Toxicology, University of Graz, 8010, Graz, Austria
| | - John Fassett
- Department of Pharmacology and Toxicology, University of Graz, 8010, Graz, Austria.
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Pharmacological mechanisms of sodium-glucose co-transporter 2 inhibitors in heart failure with preserved ejection fraction. BMC Cardiovasc Disord 2022; 22:261. [PMID: 35689186 PMCID: PMC9188076 DOI: 10.1186/s12872-022-02693-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/25/2022] [Indexed: 02/06/2023] Open
Abstract
Background More and more evidence indicates sodium-glucose co-transporter 2 inhibitors (SGLT2is) may display clinical benefits for heart failure with preserved ejection fraction (HFpEF). However, the mechanisms of the action remain unclear. Methods A systematic pharmacology-based strategy was applied for predicting the potential molecular mechanisms of SGLT2is in HFpEF. The potential targets of SGLT2is and HFpEF were contained from diverse databases. After networks were constructed, Metascape was applied to functional enrichment. Moreover, the key findings were validated through molecular docking. Results We obtained 487 SGLT2is related targets and 1505 HFpEF related targets. The networks showed the complex relationship of HFpEF-target-HFpEF. The results of functional enrichment analysis suggested that several biological processes, including muscle system process, inflammatory response, vasculature development, heart development, regulation of MAPK cascade, positive regulation of ion transport, negative regulation of cell population proliferation, cellular response to nitrogen compound, apoptotic signaling pathway, multicellular organismal homeostasis, response to oxidative stress, regulation of cell adhesion, positive regulation of cell death, response to growth factor, and cellular response to lipid, and signaling pathways, such as cardiomyopathy, cAMP signaling pathway, cytokine-cytokine receptor interaction, apoptosis, MAPK signaling pathway, HIF-1 signaling pathway, calcium signaling pathway, and NF-kappa B signaling pathway. Finally, we validated the interactions and combinations of SGLT2is and core targets. Conclusion SGLT2is play the potential role of anti-HFpEF through the direct or indirect synergy of multiple targets and pathways. Our study promotes the explanation of the molecular mechanisms of SGLT2is in HFpEF. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02693-8.
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Li H, Xia YY, Xia CL, Li Z, Shi Y, Li XB, Zhang JX. Mimicking Metabolic Disturbance in Establishing Animal Models of Heart Failure With Preserved Ejection Fraction. Front Physiol 2022; 13:879214. [PMID: 35592030 PMCID: PMC9110887 DOI: 10.3389/fphys.2022.879214] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 03/30/2022] [Indexed: 01/10/2023] Open
Abstract
Heart failure (HF), the terminal state of different heart diseases, imposed a significant health care burden worldwide. It is the last battlefield in dealing with cardiovascular diseases. HF with preserved ejection fraction (HFpEF) is a type of HF in which the symptoms and signs of HF are mainly ascribed to diastolic dysfunction of left ventricle, whereas systolic function is normal or near-normal. Compared to HF with reduced ejection fraction (HFrEF), the diagnosis and treatment of HFpEF have made limited progress, partly due to the lack of suitable animal models for translational studies in the past. Given metabolic disturbance and inflammatory burden contribute to HFpEF pathogenesis, recent years have witnessed emerging studies focusing on construction of animal models with HFpEF phenotype by mimicking metabolic disorders. These models prefer to recapitulate the metabolic disorders and endothelial dysfunction, leading to the more detailed understanding of the entity. In this review, we summarize the currently available animal models of HFpEF with metabolic disorders, as well as their advantages and disadvantages as tools for translational studies.
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Affiliation(s)
- Hui Li
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yi-Yuan Xia
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chun-Lei Xia
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Intensive Medicine, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Zheng Li
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yi Shi
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiao-Bo Li
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- *Correspondence: Xiao-Bo Li, ; Jun-Xia Zhang,
| | - Jun-Xia Zhang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- *Correspondence: Xiao-Bo Li, ; Jun-Xia Zhang,
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10
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Targeting the Metabolic-Inflammatory Circuit in Heart Failure With Preserved Ejection Fraction. Curr Heart Fail Rep 2022; 19:63-74. [PMID: 35403986 DOI: 10.1007/s11897-022-00546-1] [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] [Accepted: 03/25/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE OF REVIEW Heart failure with preserved ejection fraction (HFpEF) is a leading cause of morbidity and mortality. The current mechanistic paradigm supports a comorbidity-driven systemic proinflammatory state that evokes microvascular and myocardial dysfunction. Crucially, diabetes and obesity are frequently prevalent in HFpEF patients; as such, we review the involvement of a metabolic-inflammatory circuit in disease pathogenesis. RECENT FINDINGS Experimental models of diastolic dysfunction and genuine models of HFpEF have facilitated discovery of underlying drivers of HFpEF, where metabolic derangement and systemic inflammation appear to be central components of disease pathophysiology. Despite a shared phenotype among these models, molecular signatures differ depending on type and combination of comorbidities present. Inflammation, oxidative stress, hypertension, and metabolic derangements have been positioned as therapeutic targets to suppress the metabolic-inflammatory circuit in HFpEF. However, the stratification of unique patient phenogroups within the collective HFpEF subgroup argues for specific interventions for distinct phenogroups.
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11
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Fopiano KA, Jalnapurkar S, Davila AC, Arora V, Bagi Z. Coronary Microvascular Dysfunction and Heart Failure with Preserved Ejection Fraction - implications for Chronic Inflammatory Mechanisms. Curr Cardiol Rev 2022; 18:e310821195986. [PMID: 34488616 PMCID: PMC9413735 DOI: 10.2174/1573403x17666210831144651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/01/2021] [Accepted: 06/14/2021] [Indexed: 11/22/2022] Open
Abstract
Coronary Microvascular Dysfunction (CMD) is now considered one of the key underlying pathologies responsible for the development of both acute and chronic cardiac complications. It has been long recognized that CMD contributes to coronary no-reflow, which occurs as an acute complication during percutaneous coronary interventions. More recently, CMD was proposed to play a mechanistic role in the development of left ventricle diastolic dysfunction in heart failure with preserved ejection fraction (HFpEF). Emerging evidence indicates that a chronic low-grade pro-inflammatory activation predisposes patients to both acute and chronic cardiovascular complications raising the possibility that pro-inflammatory mediators serve as a mechanistic link in HFpEF. Few recent studies have evaluated the role of the hyaluronan-CD44 axis in inflammation-related cardiovascular pathologies, thus warranting further investigations. This review article summarizes current evidence for the role of CMD in the development of HFpEF, focusing on molecular mediators of chronic proinflammatory as well as oxidative stress mechanisms and possible therapeutic approaches to consider for treatment and prevention.
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Affiliation(s)
- Katie Anne Fopiano
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Sawan Jalnapurkar
- Division of Cardiology, Department of Medicine, Medical College of Georgia, Augusta University Augusta, GA 30912, USA
| | - Alec C Davila
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Vishal Arora
- Division of Cardiology, Department of Medicine, Medical College of Georgia, Augusta University Augusta, GA 30912, USA
| | - Zsolt Bagi
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
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12
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Zhou G, Sun S, Yuan Q, Zhang R, Jiang P, Li G, Wang Y, Li X. Multiple-Tissue and Multilevel Analysis on Differentially Expressed Genes and Differentially Correlated Gene Pairs for HFpEF. Front Genet 2021; 12:668702. [PMID: 34306013 PMCID: PMC8296822 DOI: 10.3389/fgene.2021.668702] [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] [Received: 02/17/2021] [Accepted: 05/12/2021] [Indexed: 11/15/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a complex disease characterized by dysfunctions in the heart, adipose tissue, and cerebral arteries. The elucidation of the interactions between these three tissues in HFpEF will improve our understanding of the mechanism of HFpEF. In this study, we propose a multilevel comparative framework based on differentially expressed genes (DEGs) and differentially correlated gene pairs (DCGs) to investigate the shared and unique pathological features among the three tissues in HFpEF. At the network level, functional enrichment analysis revealed that the networks of the heart, adipose tissue, and cerebral arteries were enriched in the cell cycle and immune response. The networks of the heart and adipose tissues were enriched in hemostasis, G-protein coupled receptor (GPCR) ligand, and cancer-related pathway. The heart-specific networks were enriched in the inflammatory response and cardiac hypertrophy, while the adipose-tissue-specific networks were enriched in the response to peptides and regulation of cell adhesion. The cerebral-artery-specific networks were enriched in gene expression (transcription). At the module and gene levels, 5 housekeeping DEGs, 2 housekeeping DCGs, 6 modules of merged protein–protein interaction network, 5 tissue-specific hub genes, and 20 shared hub genes were identified through comparative analysis of tissue pairs. Furthermore, the therapeutic drugs for HFpEF-targeting these genes were examined using molecular docking. The combination of multitissue and multilevel comparative frameworks is a potential strategy for the discovery of effective therapy and personalized medicine for HFpEF.
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Affiliation(s)
- Guofeng Zhou
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Shaoyan Sun
- School of Mathematics and Statistics, Ludong University, Yantai, China
| | - Qiuyue Yuan
- CEMS, NCMIS, MDIS, Academy of Mathematics and Systems Science, Chinese Academy of Sciences, Beijing, China.,School of Mathematical Sciences, University of Chinese Academy of Sciences, Beijing, China
| | - Run Zhang
- School of Mathematics and Statistics, Ludong University, Yantai, China
| | - Ping Jiang
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Guangyu Li
- CEMS, NCMIS, MDIS, Academy of Mathematics and Systems Science, Chinese Academy of Sciences, Beijing, China
| | - Yong Wang
- CEMS, NCMIS, MDIS, Academy of Mathematics and Systems Science, Chinese Academy of Sciences, Beijing, China.,School of Mathematical Sciences, University of Chinese Academy of Sciences, Beijing, China
| | - Xiao Li
- Department of Cardiovascular, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
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13
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Camici PG, Tschöpe C, Di Carli MF, Rimoldi O, Van Linthout S. Coronary microvascular dysfunction in hypertrophy and heart failure. Cardiovasc Res 2020; 116:806-816. [PMID: 31999329 DOI: 10.1093/cvr/cvaa023] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/05/2019] [Accepted: 01/23/2020] [Indexed: 12/12/2022] Open
Abstract
Left ventricular (LV) hypertrophy (LVH) is a growth in left myocardial mass mainly caused by increased cardiomyocyte size. LVH can be a physiological adaptation to physical exercise or a pathological condition either primary, i.e. genetic, or secondary to LV overload. Patients with both primary and secondary LVH have evidence of coronary microvascular dysfunction (CMD). The latter is mainly due to capillary rarefaction and adverse remodelling of intramural coronary arterioles due to medial wall thickening with an increased wall/lumen ratio. An important feature of this phenomenon is the diffuse nature of this remodelling, which generally affects the coronary microvessels in the whole of the left ventricle. Patients with LVH secondary to arterial hypertension can develop both heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). These patients can develop HFrEF via a 'direct pathway' with an interval myocardial infarction and also in its absence. On the other hand, patients can develop HFpEF that can then progress to HFrEF with or without interval myocardial infarction. A similar evolution towards LV dysfunction and both HFpEF and HFrEF can occur in patients with hypertrophic cardiomyopathy, the most common genetic cardiomyopathy with a phenotype characterized by massive LVH. In this review article, we will discuss both the experimental and clinical studies explaining the mechanisms responsible for CMD in LVH as well as the evidence linking CMD with HFpEF and HFrEF.
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Affiliation(s)
- Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milano, Italy
| | - Carsten Tschöpe
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ornella Rimoldi
- Vita Salute University and San Raffaele Hospital, Milano, Italy.,CNR IBFM, Segrate, Italy
| | - Sophie Van Linthout
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
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14
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Schauer A, Draskowski R, Jannasch A, Kirchhoff V, Goto K, Männel A, Barthel P, Augstein A, Winzer E, Tugtekin M, Labeit S, Linke A, Adams V. ZSF1 rat as animal model for HFpEF: Development of reduced diastolic function and skeletal muscle dysfunction. ESC Heart Fail 2020; 7:2123-2134. [PMID: 32710530 PMCID: PMC7524062 DOI: 10.1002/ehf2.12915] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/02/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022] Open
Abstract
AIMS The prevalence of heart failure with preserved ejection fraction (HFpEF) is still increasing, and so far, no pharmaceutical treatment has proven to be effective. A key obstacle for testing new pharmaceutical substances is the availability of suitable animal models for HFpEF, which realistically reflect the clinical picture. The aim of the present study was to characterize the development of HFpEF and skeletal muscle (SM) dysfunction in ZSF1 rats over time. METHODS AND RESULTS Echocardiography and functional analyses of the SM were performed in 6-, 10-, 15-, 20-, and 32-week-old ZSF1-lean and ZSF1-obese. Furthermore, myocardial and SM tissue was collected for molecular and histological analyses. HFpEF markers were evident as early as 10 weeks of age. Diastolic dysfunction, confirmed by a significant increase in E/e', was detectable at 10 weeks. Increased left ventricular mRNA expression of collagen and BNP was detected in ZSF1-obese animals as early as 15 and 20 weeks, respectively. The loss of muscle force was measurable in the extensor digitorum longus starting at 15 weeks, whereas the soleus muscle function was impaired at Week 32. In addition, at Week 20, markers for aortic valve sclerosis were increased. CONCLUSIONS Our measurements confirmed the appearance of HFpEF in ZSF1-obese rats as early as 10 weeks of age, most likely as a result of the pre-existing co-morbidities. In addition, SM function was reduced after the manifestation of HFpEF. In conclusion, the ZSF1 rat may serve as a suitable animal model to study pharmaceutical strategies for the treatment of HFpEF.
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Affiliation(s)
- Antje Schauer
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Runa Draskowski
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Anett Jannasch
- Department of Cardiac Surgery, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Heart Centre Dresden, Dresden, Germany
| | - Virginia Kirchhoff
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Keita Goto
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Anita Männel
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Peggy Barthel
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Antje Augstein
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Ephraim Winzer
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Malte Tugtekin
- Department of Cardiac Surgery, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Heart Centre Dresden, Dresden, Germany
| | - Siegfried Labeit
- Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany.,Myomedix GmbH, Neckargemünd, Germany
| | - Axel Linke
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany.,Dresden Cardiovascular Research Institute and Core Laboratories GmbH, Dresden, Germany
| | - Volker Adams
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany.,Dresden Cardiovascular Research Institute and Core Laboratories GmbH, Dresden, Germany
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15
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Davila A, Tian Y, Czikora I, S Weissman A, Weinand N, Dong G, Xu J, Li J, Su H, Kapuku G, Huo Y, Bagi Z. Adenosine kinase inhibition enhances microvascular dilator function and improves left ventricle diastolic dysfunction. Microcirculation 2020; 27:e12624. [PMID: 32352607 DOI: 10.1111/micc.12624] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/10/2020] [Accepted: 04/26/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Inhibition of adenosine kinase (ADK), via augmenting endogenous adenosine levels exerts cardiovascular protection. We tested the hypothesis that ADK inhibition improves microvascular dilator and left ventricle (LV) contractile function under metabolic or hemodynamic stress. METHODS AND RESULTS In Obese diabetic Zucker fatty/spontaneously hypertensive heart failure F1 hybrid rats, treatment with the selective ADK inhibitor, ABT-702 (1.5 mg/kg, intraperitoneal injections for 8-week) restored acetylcholine-, sodium nitroprusside-, and adenosine-induced dilations in isolated coronary arterioles, an effect that was accompanied by normalized end-diastolic pressure (in mm Hg, Lean: 3.4 ± 0.6, Obese: 17.6 ± 4.2, Obese + ABT: 6.6 ± 1.4) and LV relaxation constant, Tau (in ms, Lean: 6.9 ± 1.5, Obese: 13.9 ± 1.7, Obese + ABT: 6.0 ± 1.1). Mice with vascular endothelium selective ADK deletion (ADKVEC KO) exhibited an enhanced dilation to acetylcholine in isolated gracilis muscle (lgEC50 WT: -8.2 ± 0.1, ADKVEC KO: -8.8 ± 0.1, P < .05) and mesenteric arterioles (lgEC50 WT: -7.4 ± 0.2, ADKVEC KO: -8.1 ± 1.2, P < .05) when compared to wild-type (WT) mice, whereas relaxation of the femoral artery and aorta (lgEC50 WT: -7.03 ± 0.6, ADKVEC KO: -7.05 ± 0.8) was similar in the two groups. Wild-type mice progressively developed LV systolic and diastolic dysfunction when they underwent transverse aortic constriction surgery, whereas ADKVEC -KO mice displayed a lesser degree in decline of LV function. CONCLUSIONS Our results indicate that ADK inhibition selectively enhances microvascular vasodilator function, whereby it improves LV perfusion and LV contractile function under metabolic and hemodynamic stress.
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Affiliation(s)
- Alec Davila
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Yanna Tian
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Istvan Czikora
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Amanda S Weissman
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Nicholas Weinand
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Guangkuo Dong
- Neuroscience and Regenerative Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Jiean Xu
- Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Jie Li
- Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Huabo Su
- Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Gaston Kapuku
- Department of Medicine, Georgia Prevention Institute, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Yuqing Huo
- Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Zsolt Bagi
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, Georgia
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16
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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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