AIMS:The etiology of coronary artery Disease (CAD) appears different for men and women, yet insights into underlying sex-specific biological mechanisms are limited. We integrated genomic and proteomic analyses to investigate sex-specific associations of the plasma-proteome with CAD. METHODS AND RESULTS:In 40,829 UK Biobank participants (free-of-CAD, baseline-365 days thereafter; 55% women; mean age 56.9 ± 8.1 years), we examined associations between 2,922 plasma proteins and incident CAD over a median follow-up of 13.7 years (IQR 13.1-14.4) using multivariable-adjusted Cox proportional hazards models. Sex-specific analyses identified 440 female exclusive and 32 male exclusive proteins associated with incident CAD (FDR-corrected p < 0.05), revealing distinct pathway enrichments, including innate immune response in women and angiogenesis in men. Causality was assessed through combined and sex-stratified two-sample Mendelian randomization (MR) using inverse-variance-weighted analyses with genome wide association summary statistics from 422,108 men (61,969 cases) and 521,695 women (27,128 cases) (UK Biobank, FinnGen freeze 9). Integration of direct sex-protein interaction analyses with sex-combined MR identified 59 proteins with evidence for sex-specific causal effects. Four proteins demonstrated concordant directionality in sex-stratified MR analyses (n = 943,803) and multivariable regression models, namely CDKN2D, MYH9, and SKAP2 (women), and CTSH (men). To assess translational relevance, prioritized targets were further evaluated in secondary major adverse cardiovascular events among carotid endarterectomy patients (MACE; Athero-Express) and acute myocardial infarction (AMI; MISSION!) using plasma proteomics and ELISA. After further top-target identification in the context of MACE and AMI, clinical drug candidates were identified through a machine learning framework, including CTSH (men), and TNFRSF4 (both sexes). CONCLUSIONS:We identified sex-specific associations of proteins and biological pathways with incident CAD. Whereas the majority of proteins had consistent associations in both men and women, our findings suggest a degree of sex-specific pathogenesis with evidence for potential causality, opening new alleys for tailored prevention strategies and clinical cardiovascular risk management.
AIMS:Mitral regurgitation (MR) pathophysiology involves increased serotonin (5-HT) receptor (HTR) expression and signaling, together with reduced 5-HT transporter (SLC6A4) expression in mitral valve interstitial cells (MVIC). The mechanosensitive calcium channels, PIEZO1 and PIEZO2, regulate cellular responses to a variety of mechanical conditions; however, PIEZO1 and PIEZO2 have not been studied in MR. We investigated the hypothesis that PIEZO1 and PIEZO2 mediate, through 5-HT mechanisms both homeostasis in normal mitral valves (nMV) and in the pathophysiology of MR. METHODS AND RESULTS:Immunofluorescence and Western blots demonstrated the presence of PIEZO1 and PIEZO2 in samples of explanted human nMV and MR. MVIC derived from nMV and MR leaflets also expressed PIEZO1 and PIEZO2. Single-cell RNA sequencing (scRNA-seq) analyses of nMV and MR leaflet samples from 9 MR and 5 nMV cases identified 7 different cell types: Endothelial cells, smooth muscle cells, T-cells, macrophages, and three distinct MVIC phenotypes, VIC1, VIC2, and VIC3. MVIC together comprised 97% of all valve cells, irrespective of valve pathology. In addition, scRNA-seq of nMV and MR leaflets demonstrated MVIC PIEZO1 and PIEZO2 expression, together with HTR2B and SLC6A4. MVIC cultures, with no added 5-HT, demonstrated that PIEZO1 activation with its agonist, Yoda1, increased MVIC Ca2+ uptake. This was inhibited by PIEZO1-siRNA, and Dooku1, a Yoda1 antagonist, but not PIEZO2-siRNA or noncoding-RNA. Additional MVIC studies revealed that in static MVIC cultures, PIEZO1 activation with Yoda1 downregulated SLC6A4, upregulated HTR2B, and increased 5-HT levels and protein synthesis. Cyclic tension MVIC bioreactor studies showed that either PIEZO1-siRNA or PIEZO2-siRNA mitigated tension induced SLC6A4 downregulation and increased collagen synthesis; only PIEZO2-siRNA mitigated both static and cyclic tension-induced MVIC 5-HT production. CONCLUSIONS:Our findings have identified a novel link between mechano-transduction, 5-HT production and receptor signaling, and collagen synthesis, suggesting PIEZO1, PIEZO2, and downstream 5-HT pathways as potential therapeutic targets for mitigating MR progression.
This large contemporary cohort included 3,035 patients (median age 58 years, 57% men); 56% had LGE, including 242 (8%) with LGE > 10%. Most patients have obstructive HCM (71%), 1498 (69%) of which subsequently underwent septal reduction therapy (SRT) at a median of 43 days (interquartile range [IQR] 5-107) from the CMR date (1,485 myectomies and 13 alcohol septal ablations). Over a median of 8.8 years, 331 (11%) primary endpoints occurred (295 cardiovascular deaths [9.7%] and 36 appropriate ICD discharges [1.3%]). On multivariable Cox proportional hazards analysis (adjusted for standard clinical and CMR variables, higher %LGE (1.05 per 1% increase, 95% CI 1.03-1.06; p < 0.001) was associated with primary events. Compared with no LGE, LGE ≥10% was associated with higher risk of the composite endpoint.
AIMS:Adherence with a holistic or integrated care management of atrial fibrillation (AF) based on the AF better care (ABC) pathway has been associated with improved clinical outcomes. Two prospective randomized trials (mAFA and MIRACLE-AF) have evaluated this approach. The multicentre mAFA-II trial delivered the ABC pathway via mobile health using an mAFA App, while the MIRACLE-AF trial relied on village doctors supported by telehealth in rural communities. We conducted a pooled analysis of individual participant data to assess the overall efficacy of ABC pathway-based management in patients with AF. METHODS AND RESULTS:We combined patient-level data from the mAFA-II and MIRACLE-AF trials. The primary endpoint was defined as a composite of all-cause mortality, ischaemic stroke, haemorrhagic stroke, heart failure (HF), acute coronary syndrome (ACS), and major bleeding events. The secondary endpoints included individual components and two grouped outcomes: all stroke and HF/ACS. A one-stage marginal Cox proportional hazards model stratified by trial and with robust standard errors clustered at the site level was used, with adjustment for CHA2DS2-VASc and other clinically relevant baseline variables. Cumulative event rates were estimated using Kaplan-Meier methods. Subgroup and sensitivity analyses were conducted to assess the robustness of the findings. Between-trial heterogeneity was further explored using a two-stage approach, incorporating trial-level effect estimates and inverse-variance weighting. We studied 4363 patients with AF [mean age 70.3 (SD 12.8) years; 60.5% male]. During 0.8 [SD 0.4] years of follow-up, the primary endpoint occurred in 329 (7.5%). Kaplan-Meier curves demonstrated lower cumulative incidence of events in the intervention group. On multivariable mixed-effects Cox models, the intervention group demonstrated a significantly lower risk of the primary endpoint compared to the control group (adjusted hazard ratio: 0.72; 95% confidence interval: 0.56-0.93). Subgroup analyses suggested potential effect modification, whereas sensitivity analyses consistently supported the primary findings. A two-stage analysis showed directionally consistent effects across trials for the primary endpoint. CONCLUSION:In this pooled individual participant data from two prospective randomized trials, ABC pathway-based integrated care was associated with improved clinical outcomes in patients with AF vs. usual care, with the observed benefit primarily driven by reductions in HF/ACS-related events rather than classical AF-specific outcomes, supporting further implementation studies and context-specific adoption in clinical practice.
AIMS:Inflammatory cardiomyopathy (iCMP) is a leading cause of heart failure, with limited therapeutic options. Excessive cytokine levels are implicated in adverse outcomes, but their pathomechanism in iCMP is poorly understood. We sought to identify key cytokines involved in severe iCMP and elucidate their potential contribution to cardiomyocyte injury. METHODS AND RESULTS:Cytokines were analysed in patients with severe biopsy-proven iCMP (n = 63; LVEF ≤ 35%) and validated in a national cohort (n = 425). In vitro experiments examined the effect of the top cytokines observed in severe iCMP with regards to production of reactive oxygen species (ROS) and calcium homeostasis in induced human pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) and human aortic endothelial cells (HAECs). Three proteins (COLEC-12, CRIM-1, IL-6) were associated with severe iCMP. In iPSC-CMs, these proteins increased ROS (H2DCFDA assay) and intracellular Ca2+ levels (Fluo-4AM assay), indicating cellular stress. Effects were less pronounced in HAEC. Finally, real-world data from electronic medical records suggested a possible cardioprotective effect of clinically available inhibitors targeting these cytokines, although these findings remain exploratory and require confirmation in controlled studies. CONCLUSION:COLEC-12, CRIM-1, and IL-6 are elevated in severe iCMP and induce oxidative stress and calcium dysregulation in cultured cardiomyocytes. These findings highlight their potential as possible future therapeutic targets. CLINICAL TRIAL NUMBER:ClinicalTrials.gov Identifier: NCT04265040, NCT02187263.
AIMS:Heart failure is marked by suppression of fatty acid oxidation (FAO) and mitochondrial ATP production gene expression. While transcriptional downregulation via PGC-1 and PPARα/ERRα has been well documented, the involvement of the general transcriptional machinery remains insufficiently understood. Distinct from its salutary role in many cardiac conditions, endogenous Sirt1 negatively affects cardiac function during pressure overload (PO). This study investigates how Sirt1 modulates preinitiation complex (PIC) assembly and RNA polymerase II (Pol II) recruitment during pathological PO. METHODS AND RESULTS:Cardiac-specific Sirt1 knock-out (Sirt1 cKO) mice were subjected to PO. Interaction between Sirt1 and Sub1, a protein recruiting GTFs to the gene promoter, was assessed with co-immunoprecipitation, protein pull-down and molecular docking. Pol II recruitment was evaluated with ChIP-sequencing and -qPCR analyses. The binding affinity of Sirt1 and GTF to the Sub1 GTF binding domain was assessed by immunoprecipitation and protein pull-down assays. Unbiased ChIP-sequencing and -qPCR analyses showed that Pol II binding to metabolic gene promoters was downregulated during PO, which was reversed in Sirt1 cKO mice. PO upregulated Sirt1 in the heart and increased its binding to Sub1, which interacts PPARα and ERRα, but not NF-kB. The Sirt1 binding to Sub1 competitively displaced the interaction between Sub1 and GTFs, thereby inhibiting the PIC formation at the Sub1-PPARα/ERRα complex. CONCLUSIONS:Sirt1 impairs metabolic gene transcription during PO by competitively inhibiting Sub1-mediated recruitment of GTFs and PIC formation. This repression of general transcriptional machinery contributes to the metabolic disturbance and may represent a maladaptive component of the heart failure phenotype.
AIMS:Free fatty acid receptor 4 (Ffar4) is a receptor for long-chain fatty acids that attenuates heart failure driven by increased afterload. Recent findings suggest that Ffar4 prevents ischemic injury in brain, liver, and kidney, and therefore, we hypothesized that Ffar4 would attenuate cardiac ischemic injury. METHODS AND RESULTS:Using a mouse model of ischemia-reperfusion (I/R), we found in mice with systemic deletion of Ffar4 (Ffar4KO), loss of Ffar4 impaired the recovery of left ventricular systolic function post-I/R with no effect on initial infarct size. To identify potential mechanistic explanations for the cardioprotective effects of Ffar4, we performed bulk RNAseq to compare the transcriptomes from wild-type (WT) and Ffar4KO infarcted myocardium 3-days post-I/R. The transcriptome analysis identified the downregulation of several metabolic pathways suggesting impaired mitochondrial function in the infarcted Ffar4KO myocardium. Mechanistically, basal mitochondrial function and morphology were impaired in cardiac myocytes from Ffar4KO mice corroborating the results of the transcriptome analysis. Interestingly, phosphodiesterase 6c (Pde6c), which degrades cGMP, was the most upregulated gene in the Ffar4KO heart. Further, the soluble guanylyl cyclase stimulator, vericiguat, failed to increase cGMP in Ffar4KO cardiac myocytes, suggesting increased phosphodiesterase activity. Finally, cardiac myocyte-specific overexpression of Ffar4 in vivo and activation of Ffar4 in cardiac myocytes in vitro attenuated ischemic/hypoxic injury respectively. CONCLUSIONS:Our results define a novel protective role for Ffar4 in cardiac myocytes to attenuate systolic dysfunction and prevent ischemic cardiomyopathy post I/R by preserving mitochondrial function and activating cGMP signaling.
Inflammation plays a central role in the pathophysiology of heart failure (HF), and contributes to disease progression, morbidity and mortality. However, the relationships between inflammatory cytokines and different HF subtypes are complex, heterogeneous and bidirectional. In this review, we examine inflammatory pathways, biomarker profiles and comorbidities in HF with reduced, mildly reduced and preserved ejection fraction, and summarize evidence on the use of high-sensitivity C-reactive protein as a biomarker for systemic inflammation in HF. We provide insights into emerging methodologies for biomarker discovery in HF, and discuss the use of animal models to elucidate underlying mechanisms and test potential treatment strategies. Finally, we provide an overview of the therapeutic landscape, touching on past challenges and future opportunities for the development of targeted anti-inflammatory therapies in HF.
Despite many advances in the last 75 years in the fight against cardiovascular disease mortality, it remains the leading cause of death worldwide. Despite improved therapeutic approaches, cardiovascular disease remains the leading cause of death worldwide. Mounting evidence suggests that restricting food intake to a limited period in the day or extending periods of fasting may be a lifestyle intervention that reduces progression of cardiovascular disease. Various protocols for time-restricted feeding paradigms suggest significant benefits throughout the cardiovascular system. Despite some limitations to their use, the general mechanisms is thought to revolve around circadian alignment of cellular and organ function with behavioral and environmental patterns. Here we review recent evidence in a rapidly expanding field that strives to understand how timing of food intake regulates circadian physiology of cardiovascular systems focusing on heart, vascular, and neuroendocrine physiology. We review both preclinical and clinical reports showing how timed feeding may alter organ function in both health and disease.
AIMS:Liver sinusoidal endothelial cells (LSECs) dysfunction was demonstrated to represent an early and persistent event in chronic heart failure (CHF), preceding congestive hepatopathy and contributing to the pathophysiology of the disease. However, it remains unknown whether classical CHF pharmacotherapy would reverse LSEC defenestration. Herein, we characterised the therapeutic effects of angiotensin-converting enzyme (ACE) inhibitor - perindopril, and sodium-glucose cotransporter 2 (SGLT2) inhibitor - empagliflozin - on the cardiohepatic axis and, in particular, on LSEC defenestration in the murine model of CHF. METHODS AND RESULTS:Untreated 6-month-old Tgαq*44 mice exhibited impaired systolic and diastolic cardiac function, impaired liver perfusion, and LSEC defenestration. Perindopril (2 mg/kg, 8 weeks treatment, 4- to 6-month-old Tgαq*44) significantly improved the left (LV) and right ventricular (RV) systolic function and ameliorated liver perfusion in vivo in Tgαq*44 mice. Perindopril also displayed a pronounced hepatoprotective effect, as evidenced by proteomic analysis of isolated hepatocytes, reduced TBIL, and GGT; however, the number of LSEC fenestrations was unaffected in Tgαq*44 mice treated with perindopril. Empagliflozin (300 mg/kg, 8 weeks treatment, 4- to 6- month-old Tgαq*44) not only significantly improved the LV and RV systolic function and ameliorated liver perfusion, but also improved diastolic cardiac function and significantly reduced defenestration of LSECs. CONCLUSIONS:LSEC defenestration was primarily driven by cardiac diastolic dysfunction, not by impaired liver perfusion or hepatocyte function, and was independent of biomarkers of congestive hepatopathy in the murine model of CHF in Tgαq*44 mice. As fully reversed by SGLT2-I, but not by ACE-I, LSEC defenestration arises as a target in the treatment of the cardiohepatic axis in CHF, which is not uniformly improved by CHF pharmacotherapy.
AIMS:Chronic kidney disease (CKD) is associated with uraemic cardiomyopathy characterised by early metabolic dysfunction. Elevated myocardial intracellular sodium (Naᵢ) has emerged as a driver of cardiometabolic remodelling, however, its role in CKD and therapeutic modulation remains unclear. We investigated whether dual sodium-glucose cotransporter (SGLT)1/2 inhibition with sotagliflozin (SOTA) targets Naᵢ and improves cardiac metabolism in CKD. METHODS AND RESULTS:CKD was induced in male Wistar rats by 5/6 nephrectomy and assessed after 4 weeks. Cardiac phenotype was evaluated using in vivo echocardiography and ex vivo Langendorff perfusion combined with 23Na and 31P NMR spectroscopy. CKD hearts exhibited preserved systolic but impaired diastolic function and a marked elevation in myocardial Naᵢ, identifying Naᵢ overload as an early feature of uraemic cardiomyopathy. Cardiac metabolomic profiling and flux modelling demonstrated widespread suppression of central carbon metabolism, redox imbalance despite preserved PCr/ATP. In silico electrophysiological simulations predicted Naᵢ-driven Ca2+ dysregulation consistent with in vivo diastolic dysfunction. Chronic SOTA treatment (3 weeks, in vivo) normalised myocardial Naᵢ and partially reversed metabolic remodelling. Acute SOTA exposure (20-minute, Langendorff-perfusion) similarly reduced Naᵢ in CKD hearts but not in controls, indicating a direct, disease-selective myocardial effect. Naᵢ normalisation was accompanied by improved redox state and restoration of mitochondrial metabolic flux, without changes in expression of canonical Na + -handling proteins. CONCLUSION:Myocardial Naᵢ overload emerges as an early and potentially modifiable feature of uraemic cardiomyopathy. Dual SGLT1/2 inhibition with SOTA directly lowers Naᵢ and improves cardiac metabolic homeostasis, supporting Naᵢ as a mechanistically relevant and potentially targetable pathway in CKD-related cardiac remodelling.
AIMS:Polycystin-1 (PKD1) and -2 (PKD2) are causative genes for autosomal dominant polycystic kidney disease (ADPKD), which often presents with cardiovascular manifestations by mechanisms still not completely understood. PKD1 and PKD2 have been suggested to function as mechanoreceptors in endothelial cells (ECs), transducing mechanical forces exerted by the flowing blood into downstream signalling pathways. METHODS AND RESULTS:Our zebrafish functional screening of EC mechanoreceptors identified PKD1 and PKD2 as anti-apoptotic, protective factors in the zebrafish endothelium. In mice, we show that inducible EC-specific loss of PKD1, but not PKD2, led to increased atherosclerosis. To dissect the underlying mechanisms, we performed single cell RNA sequencing and identified candidate pathways regulating EC behaviour downstream from PKD1. Knockdown of PKD1 in human aortic ECs resulted in increased EC apoptosis and decreased expression of athero-protective endothelial nitric oxide synthase (eNOS), which was mediated by thrombospondin 1 (THBS1) and cellular communication network factor 1 (CCN1). CONCLUSION:By integrating in vivo and in vitro models with -omics approaches, we have identified PKD1 as a novel regulator of EC survival and protective factor against atherosclerosis development. We conclude that therapeutic targeting of this pathway may treat atherosclerosis.
