Calsyntenin-1 Promotes Doxorubicin-induced Dilated Cardiomyopathy in Rats

PURPOSE

Doxorubicin is an important cancer chemotherapeutic agent with severe cardiotoxic effects that eventually lead to dilated cardiomyopathy (DCM). Calsyntenin-1(CLSTN1) plays a critical role in the nervous system, but its relevance in cardiovascular diseases is unknown. We investigated the significance of CLSTN1 in doxorubicin-induced DCM.

METHODS

CLSTN1 expression in doxorubicin-induced DCM rats and H9c2 cells was determined using western blotting. To further explore the functions of CLSTN1, a cardiac-specific CLSTN1 overexpression rat model was constructed. The rats were subjected to analysis using echocardiographic, hemodynamic, and electrocardiographic parameters. Potential downstream molecules in CLSTN1 overexpression heart tissue were investigated using proteomics and western blotting. Finally, a knockdown of CLSTN1 was constructed to investigate the rescue function on doxorubicin-induced cell toxicity.

RESULTS

CLSTN1 protein expression increased drastically in doxorubicin-induced DCM rats and H9c2 cells. Under doxorubicin treatment, CLSTN1 protein-specific overexpression in the heart muscle promoted cardiac chamber enlargement and heart failure, while the knockdown of CLSTN1 reduced doxorubicin-induced cardiomyocyte toxicity in vitro. At the mechanistic level, overexpression of CLSTN1 downregulated SERCA2 expression and increased the phosphorylation levels of PI3K-Akt and CaMK2.

CONCLUSION

Our findings demonstrated that CLSTN1 promotes the pathogenesis of doxorubicin-induced DCM. CLSTN1 could be a therapeutic target to prevent the development of doxorubicin-induced DCM.

Heavy burden of toxic dilated cardiomyopathy among young adults: A retrospective study and review of the literature

BACKGROUND

Dilated cardiomyopathy (DCM) is a well-described entity for heart failure (HF) with reduced left ventricular ejection fraction (LVEF). Recently, drugs and other substance of abuse have been recognized as potential triggers for DCM. The aim of this study was to assess the survival in patients under 65 years old with toxic cardiomyopathy (TCM). Left ventricular remodeling and the potential usefulness of left ventricular assist device (LVAD) was also assessed.

METHODS

Single center retrospective study from January 2003 to August 2019 at a tertiary care cardiology center identified 553 patients younger than 65 years old with LVEF <40%.

RESULTS

Two hundred and one patients (36%) had a diagnosis of idiopathic DCM. Further analysis identified 38 patients (19%) for which a TCM was the most likely etiology (amphetamine [50%], cocaine [37%], anabolic steroids [8%], and energy drinks [5%]). Despite a mean LVEF of 17±8% at presentation, most patients (n=27, 71%) had an event-free survival with guideline-directed medical therapy, and 61% (n=23) recovered a LVEF ≥40% after a median follow-up of 21±23 months. Seven patients (18%) required a LVAD and 1 (3%) patient a transplantation. All LVAD were explanted or decommissioned after a median support time of 11±4 months following partial or complete LVEF recovery.

CONCLUSION

TCM induced by substance abuse is a frequent cause of HF accounting for almost 20% of all patients with DCM of unknown etiology under 65 years of age. Treatment must be tailored on an individual basis. Mechanical circulatory support demonstrated its usefulness in carefully selected patients.

Dilated Cardiomyopathy in an Adult Renal Transplant Recipient: Recovery Upon Tacrolimus to Sirolimus Switch: A Case Report

The objective of immunosuppressive drugs used in solid organ transplantation is to achieve acceptable rejection rates, minimize infections, and prolong graft and patient survival. Cardiovascular disease is a major cause of death in kidney transplant recipients. The drugs commonly used to prevent rejection (calcineurin inhibitors [CNIs] and steroids) contribute to cardiac disease seen in transplant patients by increasing the risk of hypertension and diabetes. Direct cardiac toxicity of chemotherapeutic drugs such as doxorubicin is well-known but potential direct effect of CNIs on myocardium is less explored and understood. Cardiac toxicity a rare but serious adverse effect of tacrolimus, has been observed in patients receiving solid organ transplants such as liver, bowel and kidney. In this report, we describe a case of new onset severe dilated cardiomyopathy after kidney transplantation. Reversal of heart failure occurred after tacrolimus discontinuation and the switch to a mammalian target of rapamycin (mTOR) inhibitor: sirolimus.

Self-Maintenance of Cardiac Resident Reparative Macrophages Attenuates Doxorubicin-Induced Cardiomyopathy Through the SR-A1-c-Myc Axis

RATIONALE

Doxorubicin-induced cardiomyopathy (DiCM) is a primary cause of heart failure and mortality in cancer patients, in which macrophage-orchestrated inflammation serves as an essential pathological mechanism. However, the specific roles of tissue-resident and monocyte-derived macrophages in DiCM remain poorly understood.

OBJECTIVE

Uncovering the origins, phenotypes, and functions of proliferative cardiac resident macrophages and mechanistic insights into the self-maintenance of cardiac macrophage during DiCM progression.

METHODS AND RESULTS

Mice were administrated with doxorubicin to induce cardiomyopathy. Dynamic changes of resident and monocyte-derived macrophages were examined by lineage tracing, parabiosis, and bone marrow transplantation. We found that the monocyte-derived macrophages primarily exhibited a proinflammatory phenotype that dominated the whole DiCM pathological process and impaired cardiac function. In contrast, cardiac resident macrophages were vulnerable to doxorubicin insult. The survived resident macrophages exhibited enhanced proliferation and conferred a reparative role. Global or myeloid specifically ablation of SR-A1 (class A1 scavenger receptor) inhibited proliferation of cardiac resident reparative macrophages and, therefore, exacerbated cardiomyopathy in DiCM mice. Importantly, the detrimental effect of macrophage SR-A1 deficiency was confirmed by transplantation of bone marrow. At the mechanistic level, we show that c-Myc (Avian myelocytomatosis virus oncogene cellular homolog), a key transcriptional factor for the SR-A1-P38-SIRT1 (Sirtuin 1) pathway, mediated the effect of SR-A1 in reparative macrophage proliferation in DiCM.

CONCLUSIONS

The SR-A1-c-Myc axis may represent a promising target to treat DiCM through augmentation of cardiac resident reparative macrophage proliferation.

Comparative effects of torasemide and furosemide on gap junction proteins and cardiac fibrosis in a rat model of dilated cardiomyopathy

Cardiac fibrosis is the major hallmark of adverse cardiac remodeling in chronic heart failure (CHF) and its therapeutic targeting might help against cardiac dysfunction during chronic conditions. Diuretic agents are potentially useful in these cases, but their effects on the cardiac fibrosis pathogenesis are yet to be identified. This study was designed to identify and compare the effects of diuretic drugs torasemide and furosemide on cardiac fibrosis in a rat model of dilated cardiomyopathy induced by porcine cardiac myosin mediated experimental autoimmune myocarditis. Gap junction proteins, connexin-43 and N-cadherin, expressions were downregulated in the hearts of CHF rats, while torasemide treatment has upregulated their expression. Western blotting and immunohistochemical analysis for various cardiac fibrosis related proteins as well as histopathological studies have shown that both drugs have potential anti-fibrotic effects. Among them, torasemide has superior efficacy in offering protection against adverse cardiac remodeling in the selected rat model of dilated cardiomyopathy. In conclusion, torasemide treatment has potential anti-fibrotic effect in the hearts of CHF rats, possibly via improving the gap junction proteins expression and thereby improving the cell-cell interaction in the heart. © 2016 BioFactors, 43(2):187-194, 2017.

[Anthracycline-induced cardiotoxicity: report of fatal cases]

BACKGROUND

Anthracyclines are effective drugs in pediatrics cancer treatment. However, anthracycline-induced cardiotoxicity (AIC) is a serious adverse drug reaction that affects the survival in patients treated for childhood cancer.

CLINICAL CASES

Case 1: Nine-year-old girl with stage IV Hodgkin lymphoma with 12 epirubicin doses and a cumulative dose of 576 mg/m2. After last chemotherapy dose, the patient was admitted with systemic inflammatory response, asthenia and adinamia. Echocardiography: LVEF of 22%, SF 11% and moderate mitral regurgitation. Patient died 2 days after diagnosed with dilated cardiomyopathy secondary to anthracyclines. Case 2: Fifteen-year-old girl with stage IV Burkitt lymphoma with two epirubicin doses and a cumulative dose of 90 mg/m2. After the last cycle, the patient developed several infectious foci. Echocardiography: LVEF of 49%, SF 20% and dilated left ventricle with septal flattening. Patient died 13 days after diagnosis of dilated cardiomyopathy by anthracyclines.

CONCLUSION

AIC is a problem in pediatric patients receiving anthracyclines, monitoring is essential to detect the onset of cardiac damage to provide an intervention to prevent heart failure progress.

Myocardial T1 maps reflect histological findings in acute and chronic stages of myocarditis in a rat model

BACKGROUND

Cardiovascular magnetic resonance offers both diagnostic and prognostic information in myocarditis. Using an established animal model of myocarditis, the aim of this study was to measure myocardial T1 before the onset, in the acute and in the chronic phases of the disease and to compare its course with histological and immunohistochemistry findings.

METHODS

Male young Lewis rats were immunized with 0.25 mg porcine myocardial myosin into the rear footpads on day 0. Native and contrast-enhanced ECG-triggered cardiac MRI examinations were performed before immunization on day 0 and on days 14, 21 and 35. Left ventricular function, pre- and post- contrast T1 parameters and LGE images were assessed using Small animal look-locker inversion recovery (SALLI). For each of the indicated time points a minimum of 4 rats were randomly sacrificed for pathological investigations including conventional histology (HE and Sirius-Red staining) and immunohistochemistry (CD 68) investigations.

RESULTS

All immunized rats developed myocarditis (morbidity 100%). Histologically we observed increased wall thickness with biventricular macrophage-rich mixed inflammatory infiltrates. All rats with a histologically severe myocarditis showed increased native T1 and decreased post-contrast T1 of the myocardium.

CONCLUSIONS

The assessment of native T1 and post-contrast T1 allows accurate differentiation between healthy myocardium and myocardium with inflammation and also between the acute and chronic phases of the disease.

[A Case of Dilated Cardiomyopathy after 17 Years of Clozapine Treatment]

Clozapine-induced cardiomyopathy is a rare but fatal complication with a reported incidence of 0.4% in Japan. Clozapine-induced cardiomyopathy develops at an average of 14.4 months after initiating clozapine, and to our knowledge, has a duration no longer than seven years. We present a patient who developed dilated cardiomyopathy after 17 years of clozapine treatment and made a full recovery of cardiac function at 40 weeks after clozapine treatment cessation. A 43-year-old male with a 24-year history of schizophrenia was treated with clozapine (600 mg/day) for 17 years. No abnormal findings were revealed at follow up until he pre- sented with dyspnea with no accompanying symptoms while walking. He was suspected of worsening asthma due to his past history and lack of abnormalities of ECG and CXR. However, as he experienced gradually worsening dyspnea accompanied by listlessness and lightheaded- ness, he was referred to a cardiologist. The echocardiogram revealed left ventricular dilatation and systolic dysfunction (left ventricular ejection fraction, LVEF=40%), which made a diagno- sis of dilated cardiomyopathy. We excluded cardiac ischemia and other possible causes of dilated cardiomyopathy with cardiac catheterization and endomyocardial biopsy. Clozapine treatment was stopped and switched to olanzapine along with standard heart failure medica- tions. The symptoms and left ventricular function improved following clozapine discontinua- tion. The symptoms resolved and echocardiogram showed a LVEF of 50% within 11 weeks after treatment with clozapine was ended. LVEF was reported at 59% 40weeks after cessation of clozapine. At the present time, 32 months since ceasing clozapine treatment, no worsening of symptoms has been presented. After ceasing clozapine and inducing standard heart failure medications, the patient presented the excellent recovery and the normalization of his echocar- diogram. Despite this outcome, there is currently insufficient evidence to conclusively establish a causal relationship between clozapine and cardiomyopathy in this case. In addition, this case demonstrates that we cannot exclude cardiomyopathy due to lack of abnormal findings of ECG and CXR. Therefore, we recommend that echocardiograms should be performed annually. The mortality associated with clozapine-induced cardiomyopathy is high, so if patients undergoing therapy with clozapine develop new symptoms or signs suggestive of cardiac dysfunction such as dyspnea, a focused cardiovascular examination should be considered.

Anthracycline-induced cardiomyopathy in a dog treated with epirubicin

An 8-year-old American cocker spaniel dog was diagnosed with dilated cardiomyopathy. Four years earlier, the dog had been diagnosed with multicentric lymphoma and had received 4 cycles of multi-agent chemotherapy, including doxorubicin and epirubicin. The total cumulative dose of epirubicin was 168 mg/m(2). Dilated cardiomyopathy was considered a consequence of epirubicin toxicity.

[Chemotherapy-induced cardiotoxicity: Incidence, diagnosis and prevention]

Chemotherapy-induced cardiotoxicity is a major cause of morbidity and mortality in cancer survivor. The most clinically evident and best known cardiotoxicity is the anthracycline adverse effect with heart failure. Many cardiovascular adverse effects appear after cancer therapy: heart congestive failure, myocardial ischemia, hypertension, thromboembolic complications, arrhythmias and conduction disturbances. There are potential strategies to mitigate the risks of cardiac complications for cancer patients with physical examination, echocardiography and electrocardiogram. The management of the cardiotoxicity is variable.

Ethanol vapour induced dilated cardiomyopathy in chick embryos

OBJECTIVE

To study the effects of ethanol vapour inhalation on the heart chambers of chick embryo.

METHODS

The case-control study was conducted at the College of Physicians and Surgeons Pakistan regional centre in Islamabad from January to October 2007. Both experimental and control groups were divided into three subgroups each, based on the day of the sacrifice. Each group was dissected on day 7, day 10 and day 22 or hatching whichever was earlier. The experimental sub-groups sacrificed on day 7, day 10 and on hatching, were exposed to ethanol vapours till day 6, 9 and 9 of incubation respectively. The diameter of all 4 chambers was measured in experimental hearts and compared with age-matched controls. SPSS 10 was used for statistical analysis.

RESULTS

Ethanol vapour exposure caused widening of all heart chambers in the experimental chick embryos sacrifised on day 7 and day 10 compared to the controls. The chambers of newly hatched chick hearts showed dilatation in all the chambers except the left ventricle.

CONCLUSION

Ethanol vapour exposure during development affects the heart, resulting in the widening of all heart chambers.The exposure is as dangerous as drinking alcohol. Alcohol vapour exposure during development leads to progressive dilatation in different heart chambers, producing dilated cardiomyopathy.

Calreticulin-STAT3 signaling pathway modulates mitochondrial function in a rat model of furazolidone-induced dilated cardiomyopathy

BACKGROUND

Calreticulin is a Ca(2+)-binding chaperone of the endoplasmic reticulum which regulates the signal transducer and activator of transcription 3 (STAT3). The effects of the calreticulin-STAT3 signaling pathway on cardiac mitochondria and on the progress of dilated cardiomyopathy (DCM) are still unclear.

METHODS AND RESULTS

The DCM model was generated in rats by the daily oral administration of furazolidone. Echocardiographic and hemodynamic studies demonstrated enlarged LV dimensions and reduced systolic and diastolic functions at thirty weeks after the first furazolidone administration. Morphometric analysis showed significant myocardial degeneration, interstitial fibrosis, and mitochondrial swelling with fractured or dissolved cristae in the model group. Compared with the control group, the mitochondrial membrane potential (MMP) level of the freshly isolated cardiac mitochondria and the enzyme activities of cytochrome c oxidase and succinate dehydrogenase in the model group were significantly decreased (P<0.05). Real-time PCR and western-blot revealed the increased expression of calreticulin associated with decreased activity of STAT3 in the model group. When cultured neonatal rat cardiomyocytes were exposed to furazolidone, a dose-dependent decrease in cell viability and MMP, and the increase of apoptosis rate were observed. The mRNA and protein expression of CRT gradually increased with the increase of furazolidone concentration, associated with a gradual decrease of the STAT3 phosphorylation level both in the whole cell and mitochondrial fraction. When calreticulin was knocked down with siRNA in cardiomyocytes, these changes of cardiomyocytes and mitochondria induced by furazolidone were significantly attenuated.

CONCLUSIONS

A rat model of DCM induced by furazolidone is successfully established. The calreticulin-STAT3 signaling pathway is involved in cardiac mitochondrial injury and the progress of furazolidone induced DCM.

[Effects of xinfuli granule on cardiomyocyte apoptosis in rats with dilated heart failure induced by adriamycin]

OBJECTIVE

To investigate the effects of Xinfuli Granule (XG) on cardiomyocyte apoptosis in rats with adriamycin-induced dilated cardiomyopathy (DCM).

METHODS

Seventy-two male SD rats were randomly divided into 6 groups, i.e., the normal control group, the model group, the irbesartan group, the low dose XG group, the medium dose XG group, and the high dose XG group. The DCM heart failure rat model was established using peritoneal injection of ADR. Equal volume of normal saline was injected to those in the normal control group, once per week for 6 consecutive weeks. The medication was started from the 5th week by gastrogavage. XG was dispensed into 0.5 g/mL suspension with distilled water. The XG was administered at the daily dose of 0.675 g/kg, 1.350 g/kg, and 2.700 g/kg to those in the low dose XG group, the medium dose XG group, and the high dose XG group, respectively. Irbesartan was administered to rats in the irbesartan group at the daily dose of 50 mg/kg. Equal volume of normal saline was administered to those in the normal control group and the model group by gastrogavage, once in the morning for 4 consecutive weeks. Myocardial apoptosis was measured by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL), and the expressions of the Bcl-2 and Bax protein of cardiomyocytes were measured by immunohistochemical assay.

RESULTS

Compared with the normal control group, the cardiomyocyte apoptosis rate and Bax expression level obviously increased, but the expression of Bcl-2 and the Bcl-2/Bax ratio decreased significantly in the model group (P < 0.05). Compared with the model group, the expression of Bax and the Bcl-2/Bax ratio increased significantly in the high dose XG group and the irbesartan group (P < 0.01). The Bax expression level obviously decreased in all groups except the normal control group (P < 0.01).

CONCLUSIONS

XG could obviously attenuate cardiomyocyte apoptosis in the adriamycin-induced DCM rats, and reverse the occurrence and development of heart reconstruction. The underlying mechanism might be related to regulating and controlling the expressions of Bax and Bcl-2.

Cardioprotective effect of grape-seed proanthocyanidins on doxorubicin-induced cardiac toxicity in rats

CONTEXT

Doxorubicin (Dox) is an anthracycline antibiotic used as anticancer agent. However, its use is limited due to its cardiotoxicity which is mainly attributed to accumulation of reactive oxygen species.

OBJECTIVE

This study was conducted to assess whether the antioxidant, proanthocyanidins (Pro) can ameliorate Dox-induced cardiotoxicity in rats.

MATERIALS AND METHODS

Male Sprague-Dawely rats were divided into four groups. Group I was control. Group II received Pro (70 mg/kg, orally) once daily for 10 days. Group III received doxorubicin 15 mg/kg i.p. as a single dose on the 7th day and Group IV animals were treated with Pro once daily for 10 days and Dox on the 7th day. The parameters of study were serum biomarkers, cardiac tissue antioxidant status, ECG, and effect on aconitine-induced cardiotoxicity.

RESULTS

Cardiac toxicity of doxorubicin was manifested as a significant increase in heart rate, elevation of the ST segment, prolongation of the QT interval and an increase in T wave amplitude. In addition, Dox enhanced aconitine-induced cardiotoxicity by a significant decrease in the aconitine dose producing ventricular tachycardia (VT). Administration of Pro significantly suppressed Dox-induced ECG changes and normalized the aconitine dose producing VT. The toxicity of Dox was also confirmed biochemically by significant elevation of serum CK-MB and LDH activities as well as myocardial MDA and GSH contents and decrease in serum catalase and myocardial SOD activities. Administration of Pro significantly suppressed these biochemical changes.

DISCUSSION AND CONCLUSION

These results suggest that proanthocyanidins might be a potential cardioprotective agent against Dox-induced cardiotoxicity due to its antioxidant properties.

[Angiotensin(1-7) attenuates left ventricular dysfunction and myocardial apoptosis on rat model of adriamycin-induced dilated cardiomyopathy]

OBJECTIVE

To investigate the effect of Angiotensin(1-7) [Ang(1-7)] on left ventricular dysfunction and myocardial apoptosis on rat model of adriamycin-induced dilated cardiomyopathy (ADR-DCM).

METHODS

Weight-matched adult male Wistar rats were randomly divided into 3 groups: (1) the ADR-DCM group (n = 25), in which 2.5 mg/kg of ADR was weekly intravenously injected for 10 weeks. (2) Ang(1-7) group (n = 25), in which ADR rats were simultaneously treated with angiotensin-(1-7) (24 µg×kg(-1)×h(-1), ip.) for 12 weeks. (3) normal control group (n = 10). Hemodynamics and echocardiography examination were performed at 12 weeks. The malondialdehyde (MDA) was measured by TBA methods. The plasma concentration of AngII was determined by immunoradiometric assay. The pathological change was analyzed by histological hematoxylin-eosin staining. Myocardial apoptosis was assessed by TUNEL method. The protein expression of pro-apoptotic protein caspase-3, Bax and anti-apoptotic protein Bcl-xl in cardiomyocytes were detected by Western blot.

RESULTS

Mortality was significantly lower in Ang(1-7) group than in ADR-DCM group (16% vs. 40%, P < 0.01). Compared to the control group, left ventricular end-diastolic diameter (LVEDD), left ventricular end systolic diameter (LVESD) and left ventricular end-diastolic pressure (LVEDP) were significantly increased in ADR-DCM group (all P < 0.01) while fractional shorting (FS), +dp/dtmax and -dp/dtmax were significantly reduced in ADR-DCM group (all P < 0.01). LVEDD, LVESD and LVEDP were significantly reduced while FS, +dp/dtmax and -dp/dtmax were significantly higher in Ang(1-7) group compared to the ADR-DCM group, but still higher than the control group (all P < 0.01). The concentrations of AngII and MDA were higher in the ADR-DCM group than in the control group (P < 0.01), which were significantly reduced by Ang(1-7) treatment (P < 0.01). The TUNEL-positive cells and apoptosis index, the expression of pro-apoptotic protein caspase-3 and Bax were significantly higher while the expression of anti-apoptotic protein Bcl-xl was significantly lower in the ADR-DCM group than in the control group (all P < 0.01) which could all be partially reversed by Ang(1-7) treatment (all P < 0.01).

CONCLUSION

Ang(1-7) could significantly attenuate left ventricular dysfunction and myocardial apoptosis in this model by downregulating pro-apoptotic protein caspase-3 and Bax and upregulating anti-apoptotic protein Bcl-xl expression.

Remission of chronic anthracycline-induced heart failure with support from a continuous-flow left ventricular assist device

We report the case of a patient who had chronic anthracycline-induced cardiomyopathy that was reversed after treatment with a left ventricular assist device. A 29-year-old woman had undergone anthracycline-based chemotherapy as a teenager in 1991 and 1992 and received a diagnosis of dilated cardiomyopathy 10 years later. Optimal medical therapy had initially controlled the symptoms of heart failure. However, in June 2006, the symptoms worsened to New York Heart Association functional class IV status. We implanted a continuous-flow left ventricular assist device as a bridge to cardiac transplantation; of note, a left ventricular core biopsy at that time showed no replacement fibrosis. The patient's clinical status improved thereafter, enabling left ventricular assist device ex-plantation after 17 months. To our knowledge, this is the first report of the use of left ventricular assist device support to reverse chronic anthracycline-induced heart failure.

[About secondary phenothiazine-induced cardiomyopathy]

A total of 830 autopsy protocols and medical histories of schizophrenic patients who died between 1952 and 2007 were analysed. Dilated cardiomyopathy (DCMP) occurred much more frequently than in the study of analogous material from the general population and patients with psychiatric disorders. The difference is attributed to the prolonged neuroleptic therapy with phenothiasine preparations in schizophrenics. This inference is confirmed by their significantly smaller heart mass compared with that in the period preceding this treatment. The frequency of DCMP in these patients significantly increased with duration of neuroleptic therapy. It is concluded that phenothiasine neuroleptics are etiological factors of DCMP. It is suggested to regard DCMP as an independent nosological form and call it phenothiasine-induced cardiomyopathy (FCMP).

Anabolic steroid-induced cardiomyopathy underlying acute liver failure in a young bodybuilder

Heart failure may lead to subclinical circulatory disturbances and remain an unrecognized cause of ischemic liver injury. We present the case of a previously healthy 40-year-old bodybuilder, referred to our Intensive-Care Unit of Hepatology for treatment of severe acute liver failure, with the suspicion of toxic hepatitis associated with anabolic steroid abuse. Despite the absence of symptoms and signs of congestive heart failure at admission, an anabolic steroid-induced dilated cardiomyopathy with a large thrombus in both ventricles was found to be the underlying cause of the liver injury. Treatment for the initially unrecognized heart failure rapidly restored liver function to normal. To our knowledge, this is the first reported case of severe acute liver failure due to an unrecognized anabolic steroid-induced cardiomyopathy. Awareness of this unique presentation will allow for prompt treatment of this potentially fatal cause of liver failure.

Cardiotoxicity of 5-fluorouracil and capecitabine in a pancreatic cancer patient with a novel mutation in the dihydropyrimidine dehydrogenase gene

CONTEXT

5-fluorouracil (5-FU) is an antimetabolite that acts during the S phase of the cell cycle. Dihydropyrimidine dehydrogenase (DPD) is the initial and rate-limiting enzyme in the pathway that catabolises the pyrimidines. 5-fluorouracil and its oral prodrug capecitabine are used in the treatment of a number of solid tumors, including colorectal, breast, gastric, pancreatic, prostate, and bladder cancers. Common side effects include leukopenia, diarrhea, stomatitis, nausea, vomiting, and alopecia. Cardiotoxicity is a relatively uncommon side effect of 5-fluorouracil and capecitabine.

CASE REPORT

This article reports the case of a 63-year-old male with locally invasive pancreatic cancer who developed recurrent chest pain and ischemic electrocardiogram changes after treatment with 5-fluorouracil and capecitabine. Full sequencing of the dihydropyrimidine dehydrogenase (DPYD) gene and analysis of the thymidylate synthetase (TYMS) gene promoter region was performed. Pharmacogenetic testing revealed p453L (1358C>T) type DPYD germ line mutation. This mutation has not been reported previously in association with 5-fluorouracil induced cardiotoxicity.

CONCLUSION

Cardiotoxicity associated with 5-fluorouracil and capecitabine administration is infrequently reported in the literature and appears to be dose and schedule dependent. Genetic variations such as polymorphic abnormality of DPYD are potential causative factors for a significant portion of serious adverse reactions to 5-fluorouracil-based therapy.

[Dilated cardiomyopathy post-chemotherapy]

We describe the case of a dilated cardiomyopathy with angiographically normal coronary arteries in a 32-year-old man who underwent head and spine radiotherapy and high dose antracicline chemotherapy at the age of 5 year for acute lymphoblastic leukemia. The long-term detrimental cytotoxic effect of remote life-saving chemotherapy should be considered in survivals of leukemia.

Doxorubicin-induced cardiomyopathy treated with carvedilol

Even today, heart failure due to doxorubicin-induced dilated cardiomyopathy seems to have a poor prognosis, as it is often irreversible and relatively unresponsive to standard medical treatment. This paper describes the first case of a patient complaining of severe symptoms of congestive heart failure due to doxorubicin-induced dilated cardiomyopathy unresponsive to standard medical treatment (digoxin, diuretics, and angiotensin-converting enzyme inhibitor), who showed complete clinical recovery and significant improvement of left ventricular dysfunction after carvedilol treatment. It also illustrates the possibility that carvedilol may be a first-choice drug for the treatment of this disease.

Native BK viral nephropathy in a pediatric heart transplant recipient

BK viral nephropathy is a well-documented clinical entity in kidney transplant recipients and a significant cause of morbidity and allograft loss in affected patients. BK viral nephropathy in native kidneys of non-kidney transplant recipients is relatively uncommon, but has been reported in adult patients. We report the occurrence of BK viral nephropathy in a pediatric heart transplant recipient. A 10-yr-old boy with past history of Ewing's sarcoma underwent heart transplantation for dilated cardiomyopathy induced by previous chemotherapy with doxorubicin. Post-transplant course was complicated by grade 3A rejection and CMV colitis. He was diagnosed with native BK viral nephropathy approximately 18 months post-transplant due to mild, but persistent, elevation in serum creatinine associated with proteinuria. BK viral nephropathy affects non-kidney transplant recipients, and a high index of suspicion is necessary for early diagnosis and management of this condition.

Left ventricular function in patients with toxic cardiomyopathy and with idiopathic dilated cardiomyopathy treated with Doxorubicin

Aim of the study was to investigate LV structural and functional parameters in doxorubicin chemotherapy and idiopathic dilated cardiomyopathy as well as to study dynamics of LV systolic-diastolic dysfunction in relation to the increasing doxorubicin dosage. Patients with malignant blood diseases (with non-Hodgkin's, Hodgkin's lymphoma and chronic lymphatic leukaemia) and patients with idiopathic dilated cardiomyopathy were investigated. Patients were divided into 2 groups. The first group included 49 patients (25 men and 24 women, average age was 41.2+/-2.1) with malignant blood diseases. The second group consisted of 50 patients with idiopathic dilated cardiomyopathy (39 men and 11 women, average age was 38.8+/-9.36). Patients were divided into three subgroups according to the dose of administration of doxorubicin: I subgroup--232.2+/-5.8 mg/m(2), II subgroup--388+/-15.3 mg/m(2) and III subgroup--533.1+/-13.6 mg/m(2). The LV systolic-diastolic function was evaluated twice using echo CG. Consistent dose-dependent evolution of doxorubicin cardio toxicity was observed, which eventually resulted in development of anthracycline myocardiopathy. Doxorubicin cardio toxicity is evident as early as at low total doses (232 mg/m(2)); at a "critical dose" (356-388 mg/m(2)) LV diastolic dysfunction with clinical signs of HF develops; at a total dose of 533 mg/m(2) anthracycline dilated myocardiopathy with LV systolic-diastolic dysfunction and clinical signs of HF develops in 100% of cases. In anthracycline myocardiopathy, LV undergoes the same structural and functional mass index >120 g/m(2) and idiopathic dilated myocardiopathy: LV eccentric hypertrophy (II type LV remodelling with myocardial mass index >120 g/m(2) and relative thickness of LV posterior wall <0.44); decreased LV systolic-diastolic dimensions/volumes; LV diastolic dysfunction of the restrictive type. Etiologic factor is not so important for remodelling of left ventricle, which is the basis of clinically manifested dilated cardiomyopathy.

[Severe heart failure in consequence of late anthracycline-induced cardiotoxicity--case report]

BACKGROUND

Anthracyclines are known cardiotoxic agents. Anthracycline therapy increases the risk of long-term cardiac adverse effects in oncology patients.

CASE REPORT

We report the case of a young male patient with severe congestive heart failure. The patient was treated for childhood acute myeloid leukemia by chemotherapy containing anthracyclines. Manifest dilated cardiomyopathy was developing ten years after the termination of chemotherapy with symptoms of left ventricular heart failure. Seventeen years following the end of cytostatic therapy the patient underwent heart transplantantation as ultimum refugium.

CONCLUSIONS

Late cardiac complications may become a serious therapeutic problem. In such cases, the heart transplantation seems to be the only effective approach otherwise terminal forms of the heart failure.

[Phenothiazine-induced dilatation cardiomyopathy: selected aspects of clinical course and morphology]

The author considers selected clinical and morphological characteristics of secondary dilatation cardiomyopathy in patients with schizophrenia after long-term treatment with phenotiazine neuroleptics for the purpose of substantiating nosological self-sufficiency of this pathology (PCMP). 65 cases of PCMP (46 in men and 19 in women) were revealed at postmortem examination (2% of all autopsies or significantly higher than the general incidence of idiopathic dilatation cardiomyopathies (DCMP). Analysis of the patients" medical histories, dynamics of clinical conditions, and results of electrocardiography did not show significant differences between patients with schizophrenia and PCMP compared with mentally healthy DCPM subjects DCMP. Slightly lower heart mass was documented in the former group due to cardiovascular hypoplasia. It is concluded that phenothiazine-induced dilatation cardiomyopathy should be regarded as a separate nosological form belonging to a group of secondary DCMPs and designated as PCMP.

Can beta agonists cause dilated cardiomyopathy?

We report a case of dilated cardiomyopathy that we believe is secondary to excessive use of inhaled beta agonists. Clinicians should be mindful of this possibility when using beta agonists to treat patients with obstructive airways disease; particularly if there is already recognised left ventricular dysfunction.

Rosiglitazone and pioglitazone utilization from January 2007 through May 2008 associated with five risk-warning events

BACKGROUND

Rosiglitazone was approved by the U.S. Food and Drug Administration (FDA) for type 2 diabetes in 1999. The unique mechanism of action and low risk of hypoglycemia contributed to rapid market uptake of rosiglitazone, but safety concerns became more prominent in 2007. There were 5 major events on 4 calendar days in 2007 regarding safety concerns related to rosiglitazone in certain patients: (1) the May 21, 2007, online release of the rosiglitazone meta-analysis performed by Nissen and Wolski and the FDA safety warning on the same day; (2) the July 30, 2007, conclusion of an FDA advisory committee meeting that rosiglitazone increased cardiac ischemic risk; (3) the August 14, 2007, update of thiazolidinedione (TZD) labels with a black-box warning for heart failure; and (4) the November 14, 2007, update to the warnings and precautions section of the rosiglitazone label for coadministration of nitrate or insulin.

OBJECTIVES

To (1) describe TZD (rosiglitazone and pioglitazone) utilization trends from January 1, 2007, continuing through May 2008 amid public announcements of safety concerns and (2) determine the percentage of TZD users who had medical claims indicating increased cardiovascular (CV) risk before and after release (May 21, 2007) of the FDA safety warning and online release of the meta-analysis performed by Nissen and Wolski.

METHODS

A retrospective analysis of pharmacy claims was performed from 9 commercial plans with a combined 9 million eligible members, including a 1.4 million-member cohort from 1 of the plans for which medical claims data were available. We evaluated trends in TZD use for each month for the 17-month period from January 1, 2007, through May 31, 2008, including the percentage of TZD users at increased CV risk. In the trend analysis, for each calendar month of 2007, we calculated mean pharmacy claim counts per day per million members for each of the 2 TZD drugs and for a comparison drug, sitagliptin, a new oral hypoglycemic agent in a different class (dipeptidyl-peptidase-IV inhibitors). For the CV risk analysis, we used the database of integrated medical and pharmacy claims for the 1.4 million-member cohort to identify patients with a current days supply of a TZD on May 20, 2007, December 7, 2007, or May 20, 2008. The medical claims for all identified patients were queried back 2 years from May 20, 2007, December 7, 2007, or May 20, 2008, respectively. Rosiglitazone users at increased CV rsk were defined as those with a medical claim with a primary diagnosis for congestive heart failure (CHF; International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 428.xx or 398.91), those with a current supply of nitrate or insulin therapy, or those with ischemic heart disease, including myocardial infarction (MI; ICD-9-CM codes 410.xx through 414.xx, or surgical procedure codes [36.0x through 36.3x for removal of obstruction and insertion of stents, bypass surgery, and revascularization] in the primary diagnosis field). Pioglitazone users at increased risk were identified from medical claims with a CHF diagnosis code.

RESULTS

The average number of claims per day per million members in January 2007 was 97.3 for rosiglitazone and 107.2 for pioglitazone. The average number of claims for rosiglitazone per day per million members began to decrease in May 2007, falling to 41.0 in December 2007, for a total decrease of 58.6% from the February 2007 peak (99.1), and fell further to 31.8 in May 2008. Pioglitazone use increased 8.0% from January to June 2007 (107.2 to 115.8) and remained relatively flat through December 2007 (114.6) and through May 2008 (108.9). Sitagliptin claims increased 5-fold, at a consistent rate, from an average of 8.6 claims per day per million members in January 2007 to 43.4 in December 2007, and continued to increase to 48.7, in May 2008. Of the 5,117 rosiglitazone users on May 20, 2007, 1,296 (25.3%) were identified at increased CV risk versus 590 (22.5%) of 2,621 users on December 7, 2007 (P = 0.006), and 336 (21.8%) of 1,541 users in May 2008 (P = 0.005). Of 6,056 pioglitazone users on May 20, 2007, 170 (2.8%) had a CHF diagnosis versus 160 (2.5%) of 6,275 users on December 7, 2007 (P = 0.376), and 122 of 5,998 users in May 2008 (P = 0.006).

CONCLUSIONS

Although rosiglitazone utilization per million members declined by more than half in 2007, when CV safety concerns started to emerge, about 1 in 5 rosiglitazone users had elevated CV risk at year-end 2007 and in May 2008. About 3% of pioglitazone users in May 2007 had a diagnosis of CHF in claims history, which declined to 2% in May 2008. Insurers should consider the impact of persistent utilization of TZDs among members with CV risk factors when making formulary decisions.

[A long-term survivor after relapsed acute myeloblastic leukemia with anthracycline dilated cardiomyopathy]

We watched and analyzed patient cardiac functions especially with a "Phased tracking method" to detect rapid motion of the heart. The patient suffered from congestive heart failure while depending on anthracycline cumulative doses, but now has been living more than 10 years after relapsed acute myeloblastic leukemia. To avoid congestive heart failure with increasing highly tumoricidal anthracycline doses, cardiac function should be monitored closely in connection with treatment schedules and proposed accurate therapeutic index.

Substantia nigra MR imaging signal changes and cardiomyopathy following prenatal exposure to cocaine and heroin

Exposure to cocaine in utero results in behavioral and neurodevelopmental abnormalities that persist into adulthood. Conventional MR imaging has generally failed to reveal the expected structural lesions to explain these clinical findings. We report a case of focal MR imaging signal-intensity changes in the substantia nigra, locus ceruleus, and other selected nerve tracts and nuclei in a child exposed prenatally to cocaine and other drugs. The patient also had dilated cardiomyopathy.

[Short- and long-term therapeutic effects of combination therapy with perindopril and irbesartan in a rat model of dilated cardiomyopathy]

OBJECTIVE

To evaluate the short-term, and long-term therapeutic effects of combination therapy with perindopril and irbesartan in a rat model of dilated cardiomyopathy (DCM).

METHODS

Sprague-Dawley rats were administered adriamycin intraperitoneally to develop DCM. Grouping of rats: Group A contained normal rats, and Group B contained DCM rats. Both Group A and B were not given drug treatment. Group C and D contained DCM rats, however, Group C was administered perindopril 2mg/(kg x d) while Group D was administered perindopril 1mg/(kg x d) and irbesartan 25mg/(kg x d). Brain natriuretic peptide (BNP) was determined by enzyme linked immunosorbent assay; plasma potassium and creatinine were measured; the pathological lesions of cardiac muscle tissues were evaluated after HE staining; and the survival time of each rat during the intervention was recorded.

RESULTS

After the three-week intervention, the plasma concentrations of BNP in Group D were lower than those in Group C (P<0.05). In each group, plasma concentrations of potassium and creatinine showed no significant differences between pre-intervention and post-intervention (P>0.05); pathological lesions of cardiac muscle tissues in both Group C and D were attenuated compared with those in Group B (P<0.01), but pathological lesions of cardiac muscle tissues showed no significant differences between Group C and Group D (P>0.05). Log-rank test showed that the life span of Group C was shorter than that of Group D (P<0.05); Cox regression analysis showed that both combination therapy and monotherapy with perindopril could prolong the survival time, but the effect of combination therapy was more obvious.

CONCLUSION

Combination therapy with perindopril and irbesartan in a rat model of DCM can more effectively improve the cardiac function and long-term prognosis than those monotherapy with perindopril. Both these two treatment plans can attenuate the pathological lesions of cardiac muscle tissues, without elevating the concentrations of plasma potassium and creatinine.

Granulocyte colony-stimulating factor improves left ventricular function of doxorubicin-induced cardiomyopathy

It is not well-known yet how granulocyte colony-stimulating factor (G-CSF) affects nonischemic cardiomyopathy, though its beneficial effects on acute myocardial infarction are well-established. We hypothesize that G-CSF beneficially might affect nonischemic cardiomyopathy through the direct cardioprotective effects. Here, we show that a single injection of doxorubicin (DOX, 15 mg/kg) induced left ventricular dilatation and dysfunction in mice within 2 weeks, and that these effects were significantly attenuated by human recombinant G-CSF (100 microg/kg/day for 5 days). G-CSF also protected hearts against DOX-induced cardiomyocyte atrophy/degeneration, fibrosis, inflammatory cell infiltration and down regulation of GATA-4 and sarcomeric proteins, myosin heavy chain, troponin I and desmin, both in vivo and in vitro. Cardiac cyclooxygenase-2 was upregulated and G-CSF receptor was downregulated in DOX-induced cardiomyopathy, but both of those effects were largely reversed by G-CSF. No DOX-induced apoptotic effects were seen, nor were there any changes in tumor necrosis factor-alpha or transforming growth factor-beta1 levels. Among downstream mediators of G-CSF receptor signaling, DOX-induced cardiomyopathy involved inactivation of extracellular signal-regulated protein kinase (ERK); the ERK inactivation was reversed by G-CSF. Inhibition of ERK activation, but not cyclooxygenase-2 inhibition, completely abolished beneficial effect of G-CSF on cardiac function. G-CSF did not promote differentiation of bone marrow cells into cardiomyocytes according to the experiment using green fluorescent protein-chimeric mice, and inhibition of CXCR4+ cell homing using AMD3100 did not diminish the effect of G-CSF. Finally, G-CSF was also effective when administered after cardiomyopathy was established. In conclusion, these findings imply the therapeutic usefulness of G-CSF mainly through restoring ERK activation against DOX-induced nonischemic cardiomyopathy.

Biochemical study on the protective potential of Nardostachys jatamansi extract on lipid profile and lipid metabolizing enzymes in doxorubicin intoxicated rats

Nardostachys jatamansi is a medicinally important herb of Indian origin used for centuries in Ayurvedic and Unani systems of medicine for the treatment of various ailments. The aim of the present work is to evaluate the effect of ethanolic extract of Nardostachys jatamansi rhizomes on doxorubicin induced myocardial injury with respect to lipid metabolism in serum and heart of Wistar albino rats. Altered lipid metabolism alters the cardiac function which is mainly due to changes in the property of the cardiac cell membrane. Doxorubicin exhibits cardiotoxicity by inhibition of fatty acid oxidation in the heart. The rats treated with a single dose of doxorubicin (15 mg/kg) intraperitoneally showed an increase in serum and cardiac lipids (cholesterol, triglycerides, free fatty acids and phospholipids), along with a significant rise in serum low density lipoproteins (LDL), very low density lipoproteins (VLDL) and drop in high density lipoproteins (HDL) levels, resulting in alteration of serum and cardiac lipid metabolizing enzymes. Pretreatment with a extract of Nardostachys jatamansi (500 mg/kg) orally for seven days to doxorubicin induced rats showed a significant prevention in the lipid status with the activities of the lipid metabolizing enzymes. Histopathological observations were also in correlation with the biochemical parameters. These findings suggest that the protective and hypolipidemic effect of Nardostachys jatamansi against doxorubicin induced myocardial injury in rats could possibly be mediated through its anti lipid peroxidative properties.