Inflammation and its association with oxidative stress in dogs with heart failure

Oxidative Stress in Canine Diseases: A Comprehensive Review

Oxidative stress (OS), defined as a disruption in redox balance favoring oxidants, has emerged as a major contributor to numerous diseases in human and veterinary medicine. While several reviews have explored the implication of OS in human pathology, an exhaustive review of the canine species is lacking. This comprehensive review aims to summarize the existing literature on the role of OS in canine diseases, highlighting its potentially detrimental effect on various organs and systems. Some inconsistencies among studies exist, likely due to varying biomarkers and sample types. However, there is substantial evidence supporting the involvement of OS in the development or progression of numerous canine disorders, such as cardiovascular, oncologic, endocrine, gastrointestinal, hematologic, renal, neurologic, infectious, and parasitic diseases, among others. Additionally, this review discusses the efficacy of antioxidant and pro-oxidant therapeutic agents for these conditions. Dietary interventions to counteract OS in dogs have gained significant attention in recent years, although further research on the topic is needed. This review aims to serve as a foundational resource for future investigations in this promising field.

Pleiotropic Effects of Resveratrol on Aging-Related Cardiovascular Diseases-What Can We Learn from Research in Dogs?

Resveratrol (RES) is a polyphenol with natural anti-inflammatory and antioxidant properties. It is found in abundance in plants, i.e., grapes and mulberry fruit. In addition, synthetic forms of RES exist. Since the discovery of its specific biological properties, RES has emerged as a candidate substance not only with modeling effects on the immune response but also as an important factor in preventing the onset and progression of cardiovascular disease (CVD). Previous research provided strong evidence of the effects of RES on platelets, mitochondria, cardiomyocytes, and vascular endothelial function. In addition, RES positively affects the coagulation system and vasodilatory function and improves blood flow. Not only in humans but also in veterinary medicine, cardiovascular diseases have one of the highest incidence rates. Canine and human species co-evolved and share recent evolutionary selection processes, and interestingly, numerous pathologies of companion dogs have a human counterpart. Knowledge of the impact of RES on the cardiovascular system of dogs is becoming clearer in the literature. Dogs have long been recognized as valuable animal models for the study of various human diseases as they share many physiological and genetic similarities with humans. In this review, we aim to shed light on the pleiotropic effects of resveratrol on cardiovascular health in dogs as a translational model for human cardiovascular diseases.

Inflammatory and immune variables as predictors of survival in dogs with myxomatous mitral valve disease

BACKGROUND

We aimed to investigate the association between selected inflammatory and immune variables and survival of dogs with myxomatous mitral valve disease (MMVD). We evaluated data of 62 client-owned dogs with MMVD, grouped into preclinical, stable congestive heart failure (CHF) and unstable CHF. Univariate Cox proportional hazards regression analysis was used to quantify the association of white blood cell count, concentrations and percentages of T lymphocytes and their subtypes (T helper lymphocytes, cytotoxic T lymphocytes, double positive T lymphocytes, double negative T lymphocytes) and B lymphocytes with survival. P values < 0.1 in individual groups and P values < 0.05 in the group of all patients were considered significant. Spearman correlation coefficients between significant covariates were calculated to assess the relationships among variables and with survival.

RESULTS

In the preclinical group, percentage of double positive T lymphocytes was negatively associated with survival (hazard ratio (HR) = 2.328; P = 0.051). In the unstable CHF, T lymphocyte (HR = 1.613; P = 0.085), cytotoxic T lymphocyte (HR = 1.562; P = 0.048), double positive (HR = 1.751; P = 0.042), and double negative T lymphocyte (HR = 1.613; P = 0.096) concentrations were negatively associated with survival, as well as cytotoxic T lymphocyte (HR = 1.502; P = 0.007) concentration in the group of all patients. The percentage of T helper lymphocytes was positively associated with survival in the unstable CHF (HR = 0.604; P = 0.053) and in the group of all patients (HR = 0.733; P = 0.044). The concentration of cytotoxic T lymphocytes positively correlated with left atrial to aortic ratio (LA/Ao) (rho = 0.259, P = 0.037), and peak velocity of early diastolic mitral flow (rho = 0.259, P = 0.039), whereas the percentage of T helper lymphocytes negatively correlated with left atrial to aortic ratio (LA/Ao) (rho = -0.212, P = 0.090) and early to late mitral flow ratio (rho = -0.232, P = 0.072).

CONCLUSIONS

Cytotoxic T lymphocytes, T helper lymphocytes, double positive and double negative T lymphocytes as well as biomarkers cardiac troponin I, N-terminal pro-B-type natriuretic peptide, C-reactive protein are implicated in the progression of MMVD.

Neutrophil-to-lymphocyte ratio and red blood cell distribution width to platelet ratio and their relationships with inflammatory and antioxidant status in dogs with different stages of heart failure due to myxomatous mitral valve disease

We aimed to evaluate the red blood cell distribution width-to-platelet ratio (RDW/PLT) with other complete blood cell count (CBC) indices and their correlations with serum proinflammatory cytokines, acute phase proteins (APPs), and antioxidant biomarkers in dogs at different stages of heart failure (HF). A total of 29 dogs were divided into four groups according to the ACVIM Consensus Statement: stage-A (healthy/controls, n = 8), stage-B2 (n = 6), stage-C (n = 10), and stage-D (n = 5). Seventeen CBC indices were calculated and correlated with the measurements of inflammatory, APPs, and antioxidant biomarkers, as well as selected echocardiographic variables in all dogs. At stage-C, CBC indices were evaluated 14 days after the treatment. Statistically significant changes were observed only for RDW/PLT and neutrophil-to-lymphocyte ratio (NLR) between groups. NLR increased, but RDW/PLT deceased in dogs with HF, compared to controls (P < 0.05). There were no statistically differences between pre- and post-treatment CBC indices. There were significantly positive and negative correlations between the CBC indices, serum parameters and selected echocardiographic variables in dogs with HF(P < 0.05). ROC analysis showed the best sensitivity (57% and 68%) and specificity (100% and 57%) for NLR > 5.8 and RDW/PLT ≤ 0.057 for predicting the severity of HF, respectively. Results showed that NLR and RDW/PLT may have potential for monitoring severity of the disease and the effect of treatment in dogs with HF. Imbalances between indices of circulating blood cells can contribute to immunoinflammatory and antioxidant responses in pathogenesis of canine HF, which may provide us alternative targets to develop new diagnostic and therapeutic strategies in veterinary medicine.

Effects of Medetomidine-Butorphanol and Medetomidine-Buprenorphine on Oxidative Stress and Vital Parameters in Dogs Undergoing Ovariohysterectomy

Oxidative stress (OS) is caused by an imbalance between the production of oxygen-containing free radicals and their elimination. General anesthesia increases the production of reactive oxygen species (ROS) and therefore causes oxidative stress. Our objective was to determine the effects of medetomidine-butorphanol (MEDBUT) and medetomidine-buprenorphine (MEDBUP) on oxidative stress and cardiorespiratory parameters in dogs undergoing ovariohysterectomy (OHE). Ten healthy female dogs were randomly assigned to two groups: the MEDBUT group (n = 5) received medetomidine and butorphanol, while the MEDBUP group (n = 5) received medetomidine and buprenorphine. OS was evaluated by measuring total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress index (OSI) during five different time points (from the administration of anesthetic drugs to 2 h after surgery). The observed vital cardiorespiratory parameters included heart rate (HR), respiratory rate (fR), noninvasive systolic (SAP) and diastolic (DAP) arterial blood pressures, oxygen saturation (SpO2), end-tidal CO2 (EtCO2), and body temperature (BT). Cardiorespiratory parameters were altered at a significantly greater degree in animals sedated with MEDBUT (p < 0.05). The administration of medetomidine-butorphanol was more likely to increase OS parameters, while medetomidine-buprenorphine showed decreased levels of oxidative stress throughout the study.

Oxidative stress in dogs with chronic inflammatory enteropathy treated with allogeneic mesenchymal stem cells

The search for new biomarkers in patients with chronic inflammatory enteropathy (CIE) is ongoing in the human and veterinary medicine fields. Oxidative stress biomarkers (malondialdehyde [MDA], reduced glutathione [GSH], and albumin) have been studied in humans with chronic enteropathies, but among them, only albumin has been studied in dogs with CIE. Moreover, the effect of mesenchymal stem cell (MSCs) treatment with or without prednisone on these parameters has never been studied in dogs with CIE. These parameters were compared between healthy dogs (n = 12) and dogs with CIE, and before and 1, 3, 6, and 12 months after the treatment with MSCs alone (n = 9) or together with prednisone (n = 11). The relationship between the Canine Inflammatory Bowel Disease Activity Index (CIBDAI) and oxidative stress was evaluated. Albumin was the only parameter that significantly differed between dogs with CIE and healthy dogs (p = 0,037). Differences were observed only in albumin values after combined treatment with MSCs and prednisone. No differences were observed in MDA and GSH after treatment with MSCs with or without prednisone. Albumin could help stage canine CIE, as well as its prognosis, as has already been demonstrated, although it is essential to evaluate this parameter for its antioxidant capacity, and therefore it could be a good biomarker of oxidative stress in this pathology. However, the treatment with MSCs seems unable to modify any of the analyzed oxidative stress parameters.

Differences in Levels of Mitochondrial DNA Content at Various Stages of Canine Myxomatous Mitral Valve Disease

Myxomatous mitral valve disease (MMVD) is the most common heart disease in small-breed dogs, often leading to heart failure. Oxidative stress in MMVD can harm mitochondria, decreasing their DNA content. This study assesses dogs' oxidative stress and mitochondrial DNA at different MMVD stages. Fifty-five small-breed dogs were categorized into four groups, including: A-healthy (n = 15); B-subclinical (n = 15); C-heart failure (n = 15); and D-end-stage MMVD (n = 10). Serum malondialdehyde (MDA) and mitochondrial DNA in peripheral blood were analyzed. Quantitative real-time PCR measured mitochondrial DNA, and PCR data were analyzed via the fold-change Ct method. Serum MDA levels were assessed using competitive high-performance liquid chromatography (HPLC). Mitochondrial DNA was significantly lower in group B (-0.89 ± 2.82) than in group A (1.50 ± 2.01), but significantly higher in groups C (2.02 ± 1.44) and D (2.77 ± 1.76) than B. MDA levels were notably elevated in groups B (19.07 ± 11.87 µg/mL), C (23.41 ± 12.87 μg/mL), and D (19.72 ± 16.81 μg/mL) in comparison to group A (9.37 ± 4.67 μg/mL). Nevertheless, this observed difference did not reach statistical significance. It is noteworthy that mitochondrial DNA content experiences a decline during the subclinical stage but undergoes an increase in cases of heart failure. Concurrently, oxidative stress exhibits an upward trend in dogs with MMVD. These findings collectively suggest a potential association between mitochondrial DNA, oxidative stress, and the progression of MMVD in small-breed dogs.

Hemolysis, icterus and lipemia interfere with the determination of two oxidative stress biomarkers in canine serum

BACKGROUND

Oxidative stress has been proven to play a role in numerous human and canine diseases. Among the biomarkers of oxidative stress, Thiobarbituric Acid Reactive Substances (TBARS) and Total Antioxidant Status (TAS) are two of the most widely used. Preanalytical factors are crucial for obtaining accurate results in these assays. Hemolysis, icterus and lipemia (HIL) are common sources of preanalytical errors in the laboratory; however, limited information is available regarding the considerations for canine specimens. Therefore, the objective of this study was to evaluate the potential interferences of HIL in the determination of TBARS and TAS in canine serum.

METHODS

Solutions of pooled canine serum samples were prepared by adding increasing concentrations of hemolysate, bilirubin and a synthetic lipid emulsion. TBARS and TAS were determined, and biases from the control value caused by the interfering substances were calculated.

RESULTS

Hemolysis, icterus and lipemia induced significant interferences on TBARS and TAS, albeit to varying degrees depending on the specific biomarker and interfering substance. TBARS appeared to be more susceptible to interferences in this study. Slight hemolysis, moderate icterus and slight lipemia caused notable deviations in TBARS values, surpassing the acceptable threshold for interference. TAS assay was also affected by HIL, although to a lesser extent compared to TBARS. Significant biases from TAS control value were observed when icterus was moderate, and when hemolysis and lipemia were more pronounced.

CONCLUSIONS

In light of our results, we conclude that hemolyzed, icteric and lipemic specimens are not suitable for TBARS and TAS determination in canine serum. Our findings hold considerable practical utility, as a simple visual inspection would be sufficient for identifying and excluding such specimens.

Evaluation of antioxidant status and lipid peroxidation in dogs with myxomatous mitral valve degeneration stage B1

Myxomatous mitral valve degeneration (MMVD) is the most common naturally occurring heart disease in dogs. There is a lack of data on antioxidant status and oxidative damage in dogs with MMVD stage B1 according to the American College of Veterinary Internal Medicine (ACVIM B1). The aim of this study was to investigate antioxidant status (plasma vitamin E, lipid-standardized vitamin E (LS-VitE), antioxidant capacity of lipid-(ACL) and water-soluble antioxidants, whole blood glutathione peroxidase and erythrocyte superoxide dismutase), and lipid peroxidation [malondialdehyde (MDA)] in dogs with MMVD ACVIM B1. Serum cholesterol and triglyceride concentrations were measured to calculate LS-VitE. Fourteen dogs with MMVD ACVIM B1 and 12 control dogs were included in the study. Dogs with MMVD had significantly higher vitamin E, ACL, MDA, and cholesterol concentrations and significantly higher LS-VitE values than control dogs. No significant correlations between MDA and antioxidant parameters were determined in either group. In conclusion, oxidative damage to lipids is already present and the antioxidant status is altered but not depleted in dogs with MMVD ACVIM B1. The antioxidant response to increased oxidative damage consists mainly of the activation of fat-soluble antioxidants. Further research is needed to evaluate the efficacy and targets of early antioxidant supplementation to prevent or ameliorate oxidative stress and mitigate disease progression in dogs with early-stage MMVD.

Prognostic Efficacy of Complete Blood Count Indices for Assessing the Presence and the Progression of Myxomatous Mitral Valve Disease in Dogs

This study investigated the complete blood count (CBC) indices, including neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) in dogs with myxomatous mitral valve disease (MMVD) and analyzed their correlation with conventional biomarkers, as well as the effect of CBC indices on survival time in dogs with MMVD. Medical records of 75 healthy controls and 249 dogs with MMVD from March 2015 to October 2022 were analyzed. The NLR, MLR, and PLR were calculated by dividing the absolute counts of the CBC parameters. Dogs with MMVD had significantly higher NLR, MLR, and PLR than healthy dogs (all p < 0.0001), especially those in the symptomatic MMVD group with pulmonary edema (p < 0.0001, p = 0.0002, and p = 0.0387, respectively). The NLR and MLR were significantly correlated with N-terminal pro-B type natriuretic peptide levels (both p < 0.0001). The CBC indices showed potential as biomarkers for detecting the presence of MMVD (all p < 0.0001) and severity of MMVD (p < 0.0001, p < 0.0001, and p = 0.006, respectively) using receiver operating characteristic curve analysis. The negative effects of increased NLR, MLR, and PLR on survival were confirmed using Kaplan-Meier curve analysis. In conclusion, NLR, MLR, and PLR could be cost-effective and readily available potential diagnostic and prognostic biomarkers for MMVD in dogs.

Global trends in research on oxidative stress related to heart failure from 2012 to 2021: a bibliometric analysis and suggestion to researchers

Background

Oxidative stress leads to an increase in reactive oxygen in the body. During heart failure (HF), when the body's antioxidant defense system fails to remove excessive reactive oxygen species, myocardial cells will be damaged or even die. Over the past ten years, the number of research publications on oxidative stress related to HF has increased.

Methods

We searched publications published in 2012-2021 and the Web of Science Core Collection (WoSCC) recording information. Based on the VOSviewer and CiteSpace, we conducted a bibliometric analysis of the overall distribution of journals, keywords, authors, major countries, annual output, active institutions, and cocited literature. The Global Citation Score (GCS) was used to evaluate the impact and quality of highly cited papers.

Results

We retrieved 5,616 articles and reviews. Over the past ten years, the number of annual publications on oxidative stress related to HF has increased. USA has published the largest number of articles and obtained the highest number of citations (NC) and H-index. The University of California and PLoS One are the most productive affiliations and journals in terms of publications on oxidative stress related to HF. The GCS of articles written by Paulus WJ in 2013 was 1,632, which was the top ranking. The most frequent keywords are "oxidative stress", "heart failure", "inflammation", "dysfunction" and "apoptosis". The top three authors are Kang Yuming, Ren Jun and Okoshi Katashi. "Impact", "induced myocardial infarction", "cardiovascular outcome", "empagliflozin", "sglt2 inhibitor", "protect", and "Na⁺/H⁺ exchanger" have become popular research topics.

Conclusions

Our research shows the research focus and development trends of oxidative stress related to HF in the past decade. Understanding the most important indicators of oxidative stress related to HF and the hot spots in the field of oxidative stress research related to HF can assist scholars, countries and policy-makers in the field in better understanding oxidative stress related to HF and can also lead to better decisions in oxidative stress treatment.

Metabolomic profiling in dogs with dilated cardiomyopathy eating non-traditional or traditional diets and in healthy controls

Dilated cardiomyopathy (DCM), caused by genetic and environmental factors, usually progresses to heart failure, a major cause of death in elderly people. A diet-associated form of DCM was recently identified in pet dogs eating non-traditional (NT) diets. To identify potential dietary causes, we analyzed metabolomic signatures and gene set/pathway enrichment in (1) all dogs based on disease, diet, and their interactions and (2) dogs with DCM based on diet. Metabolomic analysis was performed in 38 dogs with DCM eating NT diets (DCM-NT), 8 dogs with DCM eating traditional diets, 12 healthy controls eating NT diets, and 17 healthy controls eating traditional diets. Overall, 153 and 63 metabolites differed significantly between dogs with DCM versus healthy controls and dogs eating NT versus traditional diets, respectively, with 12 metabolites overlapping both analyses. Protein-protein interaction networks and gene set enrichment analysis identified 105 significant pathways and gene sets including aging-related pathways (e.g., nuclear factor-kappa B, oxidative damage, inflammation). Seventeen metabolites differed significantly in dogs with DCM eating NT versus traditional diets (e.g., fatty acids, amino acids, legume biomarkers), suggesting different mechanisms for primary versus diet-associated DCM. Our multifaceted metabolomic assessment of DCM in dogs highlighted diet's role in some forms of DCM.

Liquiritin inhibits H2 O2 -induced oxidative stress injury in H9c2 cells via the AMPK/SIRT1/NF-κB signaling pathway

Heart failure (HF) is a serious disease with high mortality. Oxidative stress plays a vital role in its occurrence and development. Licorice is commonly used to treat HF in traditional Chinese medicine. Liquiritin, the main ingredient of licorice, has antioxidant and anti-inflammatory properties, but the mechanism against oxidative stress in cardiomyocytes has not been reported. Establishment of oxidative damage model in H9c2 cells by hydrogen peroxide (H₂ O₂ ). Liquiritin (5, 10, 20 μmol/L) could significantly prevent the loss of cell viability and decrease the apoptosis rate. It can reduce the levels of reactive oxygen species (ROS), malonedialdehyde (MDA), lactate dehydrogenase (LDH), tumor necrosis factor-alpha (TNF-α), interleukin-1β (IL-1β), interleukin-6 (IL-6), and increase the activity of ATP, superoxidedismutase (SOD), glutathione peroxide (GSH-px), glutathione reductase (GR) and catalase (CAT) to alleviate oxidative stress and inflammation in a dose-dependent manner. Liquiritin was found to be related to AMP-Activated Protein Kinase (AMPK) pathway by molecular docking. Western blotting (WB) and quantitative reverse transcription PCR (RT-qPCR) confirmed that liquiritin could promote AMPKα phosphorylation and sirtuin 1 (SIRT1) protein expression, and inhibit phosphorylation of nuclear factor kappa B p65 (NF-κB p65). Compound C, EX 527, and PDTC can reverse the effects of liquiritin, indicating that its antioxidant effect is achieved by regulating AMPK/SIRT1/NF-κB signaling pathway. PRACTICAL APPLICATIONS: Heart failure is one of the most common cardiovascular diseases, and its treatment remains a worldwide problem. Licorice is a food and dietary supplement that has been used widely in traditional Chinese medicine (TCM). Liquiritin is one of the main active components of licorice, which has antioxidant and anti-inflammatory pharmacological effects. This study revealed the mechanism of licorice against oxidative damage of H9c2 cardiomyocytes, and provided a scientific basis for liquiritin as an antioxidant in the treatment of heart failure.

Effects of Coenzyme Q10 Supplementation on Oxidative Stress Markers, Inflammatory Markers, Lymphocyte Subpopulations, and Clinical Status in Dogs with Myxomatous Mitral Valve Disease

Scarce data exist on the effects of coenzyme Q₁₀ (CoQ₁₀) supplementation in dogs with myxomatous mitral valve disease (MMVD). The purpose of this study was to investigate the effect of CoQ₁₀ supplementation on oxidative stress markers (glutathione peroxidase, F2-isoprostanes), markers of inflammation (tumor necrosis factor-α, TNF soluble receptor II, leucocytes, and their subtypes), lymphocyte subpopulations (T helper and cytotoxic T lymphocytes, including activated T lymphocytes, and B lymphocytes), and echocardiographic and clinical parameters in dogs with MMVD. In this randomized, controlled, double-blind, longitudinal study, 43 MMVD dogs in stages ACVIM (American College of Veterinary Internal Medicine classification) B2 and ACVIM C and D (congestive heart failure (CHF)) received water-soluble coenzyme Q₁₀ (100 mg twice daily) or placebo for 3 months, and 12 non-supplemented healthy dogs served as controls. All parameters were measured before and after supplementation in MMVD dogs and once in healthy dogs. CoQ₁₀ supplementation had a positive impact on neutrophil percentage, lymphocyte percentage, and lymphocyte concentration in our cohort of dogs with CHF (ACVIM C and D). Conclusion: CoQ₁₀ as an oral supplement may have benefits in terms of decreasing inflammation in dogs with MMVD and CHF.

Short-term melatonin supplementation decreases oxidative stress but does not affect left ventricular structure and function in myxomatous mitral valve degenerative dogs

Background

Cardiac wall stress and high oxidative stress are often found in cases of myxomatous mitral valve degenerative (MMVD) disease and can lead to myocardial injuries and cardiac dysfunction. Melatonin, an antioxidant, has been shown to exert cardioprotection in laboratory animal models. However, its effect on metabolic parameters and left ventricular (LV) adaptation in MMVD dogs has rarely been investigated. This clinical trial hypothesized that a melatonin supplement for 4 weeks would improve metabolic parameters, LV structure (diameters and wall thickness), and LV function in MMVD dogs. Blood profiles, echocardiograms, and oxidative stress levels were obtained from 18 dogs with MMVD stage B2 and C at baseline and after prescribed Melatonin (2 mg/kg) for 4 weeks. Eleven dogs with MMVD stage B2 and C, which received a placebo, were evaluated as a control group.

Results

In this clinical trial, the baseline plasma malondialdehyde (MDA) was no different between the treatment and placebo groups. The post-treatment plasma MDA levels (4.50 ± 0.63 mg/mL) in the treatment group was significantly decreased after 4 weeks of melatonin supplementation compared to pre-treatment levels (7.51 ± 1.11 mg/mL) (P = 0.038). However, blood profiles and LV structure and function investigated using echocardiography were found not to different between pre-and post-treatment in each group. No adverse effects were observed following melatonin supplementation.

Conclusions

This clinical trial demonstrated that a melatonin supplement for 4 weeks can attenuate oxidative stress levels in MMVD dogs, especially in MMVD stage C, but does not result in LV structural changes or LV function in MMVD dogs of either stage B2 or stage C.

Pathogenic Mechanisms Underlying Cirrhotic Cardiomyopathy

Cardiac dysfunction associated with cirrhosis in the absence of preexisting heart disease is a condition known as cirrhotic cardiomyopathy (CCM). Cardiac abnormalities consist of enlargement of cardiac chambers, attenuated systolic and diastolic contractile responses to stress stimuli, and repolarization changes. CCM may contribute to cardiovascular morbidity and mortality after liver transplantation and other major surgeries, and also to the pathogenesis of hepatorenal syndrome. The underlying mechanisms of CCM are poorly understood and as such medical therapy is an area of unmet medical need. The present review focuses on the pathogenic mechanisms responsible for development of CCM. The two major concurrent mechanistic pathways are the inflammatory phenotype due to portal hypertension, and protein/lipid synthetic/metabolic defects due to cirrhosis and liver insufficiency. The inflammatory phenotype arises from intestinal congestion due to portal hypertension, resulting in bacteria/endotoxin translocation into the systemic circulation. The cytokine storm associated with inflammation, particularly TNFα acting via NFκB depresses cardiac function. They also stimulate two evanescent gases, nitric oxide and carbon monoxide which produce cardiodepression by cGMP. Inflammation also stimulates the endocannabinoid CB-1 pathway. These systems inhibit the stimulatory beta-adrenergic contractile pathway. The liver insufficiency of cirrhosis is associated with defective synthesis or metabolism of several substances including proteins and lipids/lipoproteins. The protein defects including titin and collagen contribute to diastolic dysfunction. Other protein abnormalities such as a switch of myosin heavy chain isoforms result in systolic dysfunction. Lipid biochemical changes at the cardiac sarcolemmal plasma membrane result in increased cholesterol:phospholipid ratio and decreased membrane fluidity. Final common pathway changes involve abnormal cardiomyocyte intracellular ion kinetics, particularly calcium. In conclusion, cirrhotic cardiomyopathy is caused by two pathways of cellular and molecular dysfunction/damage due to hepatic insufficiency and portal hypertension.