Preclinical research in cancer therapy-related cardiovascular toxicity (CTR-CVT) is a major domain of cardio-oncology and has provided biological explanation for the cardiovascular adverse effects of many cancer therapies. However, the choice of the experimental models to investigate the mechanisms of CTR-CVT is often based on personal experience and opinion, rather than on established principles and available evidence. Moreover, presentation of methods and results is frequently approximate. This Scientific Statement outlines potential quality standards regarding methodology and reporting in preclinical cardio-oncology research, with the goal of promoting accurate, reliable, and reproducible studies. Quality standards are distinguished in first-tier, when considered essential for robustness unless there is a strong justification for their omission, and second-tier standards, when desirable, but not necessary. First-tier standards ensure credible, self-sustaining research, while second-tier ones enhance quality of investigations and accelerate understanding of CTR-CVT. Adherence to the proposed quality standards is expected to benefit researchers embarking on new investigations, facilitate funding allocation, and inform the development of novel oncological therapies, eventually moving cardio-oncology science forward.

Carotid intima-media thickness (cIMT), amyloid-β1-40 (Aβ1-40), and oxidative stress are markers of vascular aging and cardiovascular risk. We compared the effects of insulin, glucagon-like peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT-2i), and their combination on the aforementioned markers in type 2 diabetes (T2DM). We prospectively studied 183 metformin-treated T2DM patients, propensity-score-matched to 12-mo treatment with insulin, liraglutide, empagliflozin, or liraglutide plus empagliflozin. Six-segment cIMT and plaque-equivalent lesions (cIMT ≥ 1.5 mm) were assessed at baseline, 6, and 12 mo; plasma Aβ1-40 and malondialdehyde (MDA) were measured. All regimens were associated with reductions in cIMT and Aβ1-40 at 12 mo (P < 0.05). MDA decreased overall with the largest reduction in GLP-1RA-based regimens. Compared with insulin, liraglutide, empagliflozin, and their combination achieved greater reductions in cIMT (-8.2, -5.6, and -10.7% vs. -1.7%, P < 0.05) and in Aβ1-40 (-52.1, -40.3, and -50.7% vs. -30.7%, P < 0.05). Patients achieving cIMT < 1.5 mm at 12 mo was the highest with combination therapy (75%), followed by liraglutide (67%) and empagliflozin (54%) versus insulin (40%; P < 0.05). Patients who regressed <1.5 mm showed greater reduction in Aβ1-40 than those with ≥1.5 mm (-56.2% vs. -25.1%, P = 0.028). Liraglutide, empagliflozin, and their combination induced greater reduction of cIMT (-8.2, -5.6, and -10.7% vs. -1.7%) and Aβ1-40 (-52.1, -40.3, and -50.7% vs. -30.7%; P < 0.05) compared with insulin. cIMT regression was associated with Aβ1-40 and MDA reductions (P < 0.05). In T2DM patients, GLP-1RA and SGLT-2i-particularly in combination-were associated with improvements in carotid atherosclerotic burden, amyloid-related vascular injury, and oxidative stress.NEW & NOTEWORTHY We investigated the effect of insulin, glucagon-like peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT-2i), and their combination on carotid intima-media thickness (cIMT) and amyloid-β1-40 (Aβ1-40) in diabetes. Twelve-month treatment with GLP-1RA, SGLT-2i, and their combination confers significant reductions in cIMT and Aβ1-40 compared with insulin. cIMT regression was associated with Aβ1-40 and malondialdehyde reductions. Our findings support that newer antidiabetic agents can favorably modify structural and biochemical markers of atherosclerosis.

Advances in the battle against cardiovascular diseases depend upon continuously translating emerging scientific knowledge from preclinical studies and clinical trials into innovative and effective therapeutic strategies. Over the past three decades, molecular and cellular biology have undergone a profound transformation, and large-scale, single-cell, and multi-omics studies have enabled investigations on cardiac disease mechanisms with unprecedented precision. However, these rapid advancements have also contributed to a divergence between the needs and aspirations of basic researchers and those of clinical scientists and practicians, to the detriment of discovery science, precision medicine, and cardiovascular healthcare. The present document highlights the importance of education and training in overcoming the gap between discovery and clinical science, by promoting a common language aimed at designing more translationally relevant and impactful discovery science. To achieve this aim, multidisciplinary efforts will be required to better define learning objectives within training programmes, including education in discovery and clinical sciences, promotion of specific mentorship paths, collaborative research efforts, promotion of equality, diversity, and inclusion, and protection of research time and activity within academic, clinical, and research careers.

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide. While studies suggest that berry fruits offer beneficial effects in CVD prevention, the bioactive compounds within different berries vary, and the specific mechanisms behind their protective effects are not yet fully elucidated. Our study aimed to evaluate and compare the cardioprotective and anti-atherosclerotic effects of Morus alba (white mulberries, WMex) and Vaccinium myrtillus L. fruit extracts (blueberries, BBex), focusing on acute myocardial infarction (AMI), CVD risk factors, atherosclerosis development, and the underlying mechanisms. WMex and BBex were produced and their qualitative compositions were characterized. We evaluated the infarct size (IS) limiting potential of 8-weeks supplementation with both WMex and BBex at nutritional doses in mice with western diet (WD)-induced metabolic syndrome (MS). We further evaluated atherosclerosis development mitigation after 4-weeks supplementation with the extracts in both male and female WD-fed ApoE-/- mice as well as the putative cardioprotective and atheroprotective mechanisms. The total flavonoids in WMex and BBex were 49.50 and 98.92 mg rutin/g extract, respectively, while the total phenolic content was 50.74 and 110.00 mg gallic acid/g extract, respectively. Both extracts limited IS compared to Control by suppressing apoptosis. WMex upregulated endothelial nitric oxide synthase (eNOS) phosphorylation and pathway along with circulating nitrite levels. WMex suppressed the extent of atheromatic area in both male and female ApoE-/- mice, while BBex was effective in females without any of the extracts affecting estrogen levels. WMex downregulated NF-kB-ICAM-1 axis in the atherosclerotic area and reduced circulating triglyceride levels. None of the extracts caused signs of toxicity, supporting a safety profile. In conclusion, WMex exerts potent cardioprotective and anti-atherosclerotic properties in vivo and could be further exploited for CVD prevention.

The interaction between inflammation and metabolism (immunometabolism) is a crucial factor in the pathophysiology of heart failure, whether the cardiac failure originates from ischaemic injury or systemic metabolic disorders, and whether it is associated with reduced or preserved ejection fraction. Ischaemia, metabolic stress and comorbidity-driven systemic inflammation attract innate and adaptive immune cells to the myocardium and induce their polarization towards pro-inflammatory or anti-inflammatory phenotypes through cell-intrinsic metabolic shifts involving oxidative phosphorylation and anaerobic glycolysis. These infiltrating immune cells modulate cardiac and systemic metabolism. The bidirectional metabolic crosstalk between immune cells and parenchymal and stromal cardiac cells contributes to adverse cardiac remodelling. In turn, ischaemic injury and deregulated metabolism stimulate bone marrow and extramedullary myelopoiesis, which increases immune cell recruitment and perpetuates a non-resolving chronic inflammatory state. Pharmacological interventions targeting metabolism have shown promise for improving outcomes in patients with heart failure, but immunomodulatory approaches face multiple challenges. Understanding the complex metabolic pathways and cell–cell interactions that regulate immunometabolism in heart failure is essential to identify new therapies that shift the balance from maladaptive to cardioprotective immune responses. In this Review, we provide a comprehensive overview of the intricate cellular and molecular mechanisms that govern immunometabolism in heart failure and discuss potential approaches to non-invasively monitor and treat patients with heart failure. In this Review, the authors discuss the cellular and molecular mechanisms of immunometabolism in heart failure and highlight potential approaches for non-invasive monitoring and for the treatment of patients with heart failure.

Animal models offer invaluable insights into disease mechanisms but cannot entirely mimic the variability and heterogeneity of human populations, nor the increasing prevalence of multi-morbidity. Consequently, employing human samples-such as whole blood or fractions, valvular and vascular tissues, myocardium, pericardium, or human-derived cells-is essential for enhancing the translational relevance of cardiovascular research. For instance, myocardial tissue slices, which preserve crucial structural and functional characteristics of the human heart, can be used in vitro to examine drug responses. Human blood serves as a rich source of biomarkers, including extracellular vesicles, various types of RNA (miRNA, lncRNA, and circRNAs), circulating inflammatory cells, and endothelial colony-forming cells, facilitating detailed studies of cardiovascular diseases. Primary cardiomyocytes and vascular cells isolated from human tissues are invaluable for mechanistic investigations in vitro. In cases where these are unavailable, human induced pluripotent stem cells serve as effective substitutes, albeit with specific limitations. However, the use of human samples presents challenges such as ethical approvals, tissue procurement and storage, variability in patient genetics and treatment regimens, and the selection of appropriate control samples. Biobanks are central to the efficient use of these scarce and valuable resources. This scientific statement discusses opportunities to implement the use of human samples for cardiovascular research within specific clinical contexts, offers a practical framework for acquiring and utilizing different human materials, and presents examples of human sample applications for specific cardiovascular diseases, providing a valuable resource for clinicians, translational and basic scientists engaged in cardiovascular research.

Background Myocardial infarct size (IS) is the gold standard end-point in shorth-term studies on cardioprotection. However, IS quantification in rodent models with standard Evans Blue and 2,3,5-triphenyltetrazolium chloride (TTC) staining is time-consuming and prone to inter-observer variance. Therefore, we aimed to develop an artificial intelligence (AI)-based application to reduce time and inter-observer variability of IS analysis in rodent acute myocardial infarction (MI) models. Methods We used TTC/Evans blue-stained heart slice images of independent laboratories from previously published projects. Rat (n = 325 and 248 slices) and mouse (n = 77 slices) datasets were used to train deep learning segmentation models with three different neural network architectures, which were combined into a single AI analysis. AI analysis was compared with manual analysis on rat data from a training laboratory (internal data, n = 496 slices, n = 41 whole-hearts) and data from independent laboratories (external data, n = 60 and 62 slices). Additionally, two independent evaluators performed manual and AI-assisted analysis, consisting of AI-analysis and its manual correction, on internal (n = 36 slices) and external data (n = 37 slices). Results Lin’s concordance correlation coefficient (CCC) between IS/AAR values from manual and AI analysis was 0.844 with 95% CI of [0.814; 0.869] for images of internal data heart slices. On external data heart slices, AI accurately annotated slice area and AAR but failed to annotate infarcted area. On internal whole-heart data, CCC between AI and AI-assisted IS/AAR was 0.894 with 95% CI of [0.812; 0.942]. AI-assisted analysis reduced evaluation time on both internal and external datasets and increased region overlap for AAR between the two independent evaluators on dependent data. Conclusions AI-assisted analysis significantly reduced analysis time and inter-observer variability. For optimal performance, lab-specific AI training is recommended. Infarctsize-AI™ is available at . Translational perspective Myocardial infarct size (IS) is the gold-standard end-point in shorth-term studies to assess potential cardioprotective therapies against acute myocardial infarction (AMI). However, IS quantification in rodent AMI models is time-consuming and prone to inter-observer variance. Therefore, we developed an AI-based software that can reduce analysis time and inter-observer variability and facilitate documentation, which facilitates the clinical translation of potential cardioprotective therapies. ![Figure][1] ### Competing Interest Statement TK is founder and director of Camoxis Ltd. PF is the founder and CEO, and ZG is the Translational Program Director of Pharmahungary Group, a group of R&D companies. All other authors declare no competing interests. European Cooperation in Science and Technology, CA22169 Ministry for Innovation and Technology in Hungary, 2020-4.1.1.-TKP2020 National Research, Development and Innovation Office (NKFIH) of Hungary, K139105, FK138223, EFOP-3.6.3-VEKOP-16-2017-00009 European Union, RRF-2.3.1-21-2022-00003 the Ministry for Culture and Innovation from the source of the National Research, Development and Innovation Fund, 2024-2.1.1-EKÖP-2024-00004 Ministry of Health, Singapore Ministry of Health’s National Medical Research Council, MOH-STaR21jun-0003, NMRC CG21APR1006 CArdiovascular DiseasE National Collaborative Enterprise, MOH-001277-01 [1]: pending:yes

Aims Activation of the transcriptional factor Krüppel-like factor 5 (KLF5) is detrimental to chronic heart failure. We explored the involvement of KLF5 in myocardial ischemia/reperfusion injury. Methods and results Yorkshire pigs underwent 75΄ of ischemia, followed by 3h or 24h of reperfusion. C57BL/6J mice underwent 30΄ of ischemia, followed by 10’, 2h, 12h, 24h, or 4 weeks of reperfusion. Hearts and isolated cardiomyocytes were analyzed for gene expression. We assessed cardiac function, infarct size (IS), oxidative stress, and fibrosis in mice subjected to pharmacologic or genetic KLF5 inhibition, as well as pharmacologic inhibition of NADPH oxidases or Glucose Transporter (GLUT)1 and GLUT4. Bulk RNA sequencing, untargeted 1H-NMR metabolomics and LC-MS lipidomics were performed. Isolated primary murine cardiomyocytes were infected with recombinant adenovirus expressing KLF5. During reperfusion, cardiοmyocyte KLF5 expression was increased in porcine and murine hearts. Pharmacologic or cardiomyocyte-specific genetic inhibition of KLF5 reduced IS and improved cardiac function in mice. Importantly, acute KLF5 inhibition during early reperfusion suppressed fibrosis and preserved systolic cardiac function 4 weeks post-ischemia/reperfusion. This improvement was associated with lower NOX4 expression, less oxidative stress, and suppressed inflammation and cell apoptosis. Pharmacologic inhibition of NOX4 conferred the same benefit. Metabolomic analysis indicated that KLF5 inhibition lowered glucose-derived metabolites (UDP-Glucose and Lactate) at early reperfusion. Accordingly, cardiac GLUT1 and GLUT4 levels were increased with ischemia/reperfusion, which was reverted by KLF5 inhibition. Pharmacologic inhibition of both GLUT1/4 reduced IS. Finally, myocardial KLF5 overexpression increased GLUT1 mRNA levels and mouse mortality. Conclusions Ischemia/reperfusion increases cardiomyocyte KLF5 expression in pigs and mice. This constitutes a central element of myocardial injury pathophysiology and is associated with stimulation of GLUT1 and GLUT4 expression, activation of NOX4, oxidative stress, inflammation and apoptosis. Acute KLF5 inhibition during reperfusion constitutes a novel therapeutic approach against myocardial ischemia/reperfusion injury.

ST elevation myocardial infarction (STEMI) patients display endothelial dysfunction. We investigated whether endothelial glycocalyx thickness is affected in STEMI patients and may predict left ventricular performance post event. We examined 278 STEMI patients and 140 matched controls. We measured: (a) perfused boundary region (PBR) of the sublingual microvessels (range 4 to 25 μm; increased value indicates reduced endothelial glycocalyx integrity) at baseline; (b) left ventricular ejection fraction (LVEF) and global longitudinal strain (LVGLS), at baseline and at 12 months, (c) the percentage change of left ventricular end-systolic volume (ΔLVESV) at 12 months. Compared with matched controls, STEMI patients had higher PBR4–25 (2.11 ± 0.17 μm vs. 1.98 ± 0.20 μm, p < 0.001). In a model including age, sex, hypertension, diabetes, hyperlipidemia, smoking, family history of coronary artery disease, number of diseased vessels, location of STEMI medication, and high-sensitivity troponin T (hs-troponin), PBR4–25 was independently associated with LVEF and LVGLS at 48 hours post-MI (for LVEF: unstandardized β coefficient: −4.71, 95% CI: −8.53 to −0.71, p = 0.019 and for LVGLS: 2.89, 95%CI: 1.63–4.16, p < 0.001). Using multivariable analysis, PBR4–25 remained a significant predictor of the percentage change in LVEF, LVGLS, and ΔLVESV at 12-month follow-up (LVEF change: unstandardized β coefficient: −1.38, 95% CI: −1.80 to −0.96, p < 0.001; for LV GLS change: −0.66, 95% CI: −1.14 to −0.18, p = 0.007 and for ΔLVESV: 1.42, 95% CI: 0.06–2.93, p = 0.039). A PBR4–25 cut-off value of 2.29 μm could detect LV EF less than 45% at 48 h as well as at 12 months (AUC: 0.82, p < 0.001 and AUC: 0.80; p < 0.001). Endothelial glycocalyx assessment is associated with myocardial performance after STEMI.

Purpose:Sirtuins (SIRTs) play a critical role in redox and metabolic regulation of the myocardium; however, the cardioprotective potential of SIRT5 in terms of infarct size (IS) reduction is still elusive. Herein, we employed the newly synthesized SIRT5-specific agonist, MC3215, developed by our group, to explore for the first time the pharmacological activation of SIRT5 as a target for cardioprotection. Methods and Results:In in vitro screening experiments, SIRT1 and SIRT5 agonists, namely, MC2606 and MC3215, at 1-20 μΜ were added to cardiomyoblasts (H9c2) and human endothelial cells (EA.hy-926) during 24 h hypoxia/2 h reoxygenation (H/R). SIRT1 and SIRT5 agonists mitigated H/R injury. Male C57BL/6J mice underwent 30 min ischemia (I) followed by 2 h or 24 h reperfusion (R). Mice received vehicle, the SIRT1 or SIRT5 agonists at 20 and 30 mg/kg at the 20th min of ischemia, and IS was quantified via triphenyl-tetrazolium chloride staining (n=5-7/group). MC3215-mediated SIRT5 activation reduced IS at 24 h R at 20mg/kg compared to controls (25.18±2.7% vs 38.80±4.7%). MC3215 treatment resulted in reduced protein malonylation in all experimental settings. Targeted mass-spectrometry-based metabolomics in the ischemic heart at the 10th min of R suggested increased fatty acid oxidation, as indicated by increased N3-Trimethyllysine and D-pantothenate. Concomitantly, molecular analysis indicated that the SIRT5 agonist activated AMPKα and Reperfusion Injury Salvage Kinase (RISK) pathway. Additionally, at 3 h reperfusion, MC3215 led to increased mitofusin 2 without altering apoptosis, paving towards improved mitochondrial dynamics. Co-administration of SIRT5 inhibitor, TW-37, abrogated MC3215-mediated cardioprotection. Conclusion:SIRT5 pharmacological agonism emerges as a novel cardioprotective target, leading to RISK pathway activation and mitochondria-related metabolic effects, converging at salvaging ischemic myocardium from I/R injury.

BACKGROUND AND AIMS:Empagliflozin (EMPA), a sodium-glucose co-transporter 2 inhibitor (SGLT2i), is cardioprotective in acute myocardial infarction (AMI) including fewer hospitalizations for heart failure. However, the underlying metabolic and immunomodulatory mechanisms remain incompletely characterized. This study investigates the metabolic effects of EMPA in diabetic and non-diabetic conditions, as well as on AMI-induced immune responses. METHODS:C57BL/6J mice were fed on either a control Chow diet (CD) or Western diet (WD) to induce hyperglycemia, followed by treatment with EMPA (10 mg/kg/day) for six weeks and subsequent AMI (30 min of ischemia/2 h of reperfusion). Infarcted hearts were subjected to metabolomic and lipidomic analyses. Cardiac necrosis and immune cell abundance were assessed 7 days post-AMI in blood, spleen, and cardiac tissue with Hematoxylin/Eosin (H/E) staining and flow cytometry, respectively. RESULTS:Besides the already established effects of EMPA in lowering body weight, blood glucose and cholesterol levels, we found that it fully restored cardiac ATP and 3-hydroxybutyrate (3-BHB) levels in mice with AMI. Additionally, it suppressed UDP-glucose and GM3 ganglioside levels. Notably, the ability of EMPA to restore cardiac metabolome and lipidome was similar between the two dietary groups, with a more pronounced effect observed in WD-fed mice. Furthermore, EMPA reduced myeloid cells in spleen (15.42 ± 2.60 % vs. 21.20 ± 4.45 %) and cardiac tissue (15.94 ± 5.93 % vs. 32.42 ± 8.77 %) and suppressed cardiac necrosis 7 days post-AMI (11.15 ± 3.42 % vs. 21.74 ± 3.30 %). CONCLUSIONS:EMPA restores cardiac energetics and attenuates the metabolic complications of AMI, independent of the presence of diabetes. These metabolic effects correlate with lower immune cell infiltration and cardiac necrosis, providing long-term benefits in AMI.

Although many cardioprotective interventions have been shown to limit infarct size (IS), in preclinical animal studies of acute myocardial ischemia/reperfusion injury (IRI), their clinical translation to patient benefit has been largely disappointing. A major factor is the lack of rigor and reproducibility in the preclinical studies. To address this, we have established the IMproving Preclinical Assessment of Cardioprotective Therapies (IMPACT) small animal multisite acute myocardial infarction (AMI) network, with centralized randomization and blinded core laboratory IS analysis, and have validated the network using ischemic preconditioning (IPC). Eight sites from the COST Innovators Grant (IG16225) network participated in the IMPACT AMI study. Mice and rats were randomly allocated into Sham, Control, or IPC groups. The IRI group underwent 45 min (mice) or 30 min (rats) of left coronary artery occlusion followed by 24 h reperfusion. IPC comprised three cycles of 5 min occlusion/reperfusion before IRI. IS was determined by a blinded core lab. The majority of site showed significant cardioprotection with IPC. In pooled mouse data, IPC ( N = 42) reduced IS/AAR by 35% compared to control ( N = 48) (30 ± 16% versus 46 ± 13%; p < 0.005), and in rat data, IPC ( N = 36) reduced IS/AAR by 29% when compared to control ( N = 39) (32 ± 19% versus 45 ± 14%; p < 0.01). The IMPACT multisite mouse and rat AMI networks, with centralized randomization and blinded core IS analysis, were established to improve the reproducibility of cardioprotective interventions in preclinical studies and to facilitate the translation of these therapies for patient benefit.

Acute myocardial infarction (MI) remains a major cause of death and disability worldwide. No adjuvant treatment has yet been fully validated in patients to limit the progression from the initial tissue damage due to acute MI, to the development of heart failure. However, mitochondria have long been demonstrated to be a key target for cardioprotective strategies to reduce cell death that leads to left ventricular dysfunction and ultimately heart failure. While pre-clinical studies have investigated several mitoprotective strategies targeting different mitochondrial functions, such as oxidative stress or permeability transition pore opening, none have shown successful clinical translation so far. In this European Society of Cardiology scientific statement, we present recent research advances in the understanding of the mitochondrial alterations occurring in MI and in the discovery of key components of mitochondrial structure and function in order to improve drug development. We discuss the reasons for the failure of clinical translation and the remaining obstacles that need to be addressed, including timing of drug administration, tissue bioavailability and efficient mitochondrial targeting, together with the mitochondrial impact derived from risk factors, comorbidities and comedications. Taken together, this scientific statement aims to provides a consensus opinion from clinicians and basic scientists to translate some of the most promising mitoprotective targets into the clinical setting to protect against MI and heart failure.

Crystalglobulinemia is a rare plasma cell dyscrasia characterized by the crystallization of monoclonal proteins within the systemic vasculature and tissues, leading to occlusive vasculopathy, nephropathy, and tissue ischemia. We investigated platelet and endothelial activation status in a patient with crystalglobulinemia presenting with thrombotic events and acute kidney injury before and after anticlonal therapy. Platelet function assessment revealed the presence of procoagulant platelets, characterized by phosphatidylserine exposure and increased P-selectin expression in the absence of external stimuli. This phenotype was reversed by ex vivo calcium chelation. Furthermore, evidence supports FcγRIIA-mediated platelet activation by crystal complexes. Platelet proteomic analysis demonstrated upregulation of complement-related proteins, apolipoproteins, and proteins involved in platelet activation pathways. In addition, crystal proteomic analysis identified immunoglobulin heavy constant gamma-1 and albumin in a 1:2 ratio. Endothelial gene expression was evaluated using real-time polymerase chain reaction after coculturing the patient's serum, isolated platelets, and citrated platelet-poor plasma with a serum-starved EA.hy926 endothelial monolayer. The patient's serum increased endothelial gene expression of ICAM-1 and ADAMTS13, whereas VCAM-1 and E-selectin were significantly reduced compared with participants, a phenotype typically observed under high shear stress conditions. Platelet and endothelial dysfunction correlated with disease activity and demonstrated partial reversal after treatment, highlighting potential implications for disease monitoring and therapeutic targeting.

Background We investigated the effects of the combined treatment with glucagon like peptide‐1 receptor agonists (GLP‐1RA) and sodium‐glucose cotransporter‐2 inhibitors (SGLT‐2i) on NT‐proBNP (N‐terminal pro‐brain natriuretic peptide), GDF‐15 (growth differentiation factor 15), and MOTS‐c (mitochondrial‐derived peptide‐c) in patients with type 2 diabetes (T2D) and high or very high cardiovascular risk. Methods We studied 163 consecutive patients with type 2 diabetes who were treated with insulin (n=40), liraglutide (n=41), empagliflozin (n=42), or their combination (GLP‐1RA+SGLT‐2i) (n=40) and were matched using propensity score analysis. We measured the following at baseline and 4 and 12 months of treatment: (1) NT‐proBNP, GDF‐15, and MOTS‐c; (2) 2,2′‐azino‐bis(3‐ethylbenzothiazoline‐6‐sulfonic acid), and (3) left ventricular global longitudinal strain, left atrial strain during atrial reservoir phase, and global work index using speckle‐tracking imaging. Results At 12 months, GLP‐1RA, SGLT‐2i, and their combination showed a greater reduction of NT‐proBNP (−43.1% versus −54.2% versus −56.9% versus −14.7%) and GDF‐15 than insulin. Only treatment with SGLT‐2i and GLP‐1RA+SGLT‐2i improved MOTS‐c. GLP‐1RA, SGLT‐2i, or GLP‐1RA+SGLT‐2i provided an increase of global longitudinal strain, left atrial strain, and global work index compared with insulin. In all patients, the reduction of NT‐proBNP was associated with the improvement of global longitudinal strain, left atrial strain during atrial reservoir phase, and global work index; the decrease of GDF‐15 with the increase of ABTS and MOTS‐c; and the increase of MOTs‐c with improved global longitudinal strain and constructive myocardial work at 12 months (P<0.05). Conclusions Twelve‐month treatment with combination of GLP‐1RA+SGLT‐2i was associated with a greater reduction of neurohumoral markers and increase of antioxidant ability than each treatment alone and insulin. SGLT‐2i appear more effective in the improvement of neurohumoral and mitochondrial activation. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03878706.

AIMS:Activation of the transcriptional factor Krüppel-like factor 5 (KLF5) is detrimental to chronic heart failure. We explored the involvement of KLF5 in myocardial ischaemia/reperfusion injury. METHODS AND RESULTS:Yorkshire pigs underwent 75' of ischaemia, followed by 3 or 24 h of reperfusion. C57BL/6J mice underwent 30' of ischaemia, followed by 10', 2, 12, 24 h, or 4 weeks of reperfusion. Hearts and isolated cardiomyocytes (CMs) were analysed for gene expression. We assessed cardiac function, infarct size (IS), oxidative stress, and fibrosis in mice subjected to pharmacologic or genetic KLF5 inhibition, as well as pharmacologic inhibition of NADPH oxidases or glucose transporter (GLUT)1 and GLUT4. Bulk RNA sequencing, untargeted 1H-NMR metabolomics, and LC-MS lipidomics were performed. Isolated primary murine CMs were infected with recombinant adenovirus expressing KLF5. During reperfusion, CM KLF5 expression was increased in porcine and murine hearts. Pharmacologic or CM-specific genetic inhibition of KLF5 reduced IS and improved cardiac function in mice. Importantly, acute KLF5 inhibition during early reperfusion suppressed fibrosis and preserved systolic cardiac function 4 weeks post-ischaemia/reperfusion. This improvement was associated with lower NADPH-oxidase 4 (NOX4) expression, less oxidative stress, and suppressed inflammation and cell apoptosis. Pharmacologic inhibition of NOX4 conferred the same benefit. Metabolomic analysis indicated that KLF5 inhibition lowered glucose-derived metabolites (UDP-glucose and lactate) at early reperfusion. Accordingly, cardiac GLUT1 and GLUT4 levels were increased with ischaemia/reperfusion, which was reverted by KLF5 inhibition. Pharmacologic inhibition of both GLUT1 and GLUT4 reduced IS. Finally, myocardial KLF5 overexpression increased GLUT1 mRNA levels and mouse mortality. CONCLUSION:Ischaemia/reperfusion increases CM KLF5 expression in pigs and mice. This constitutes a central element of myocardial injury pathophysiology and is associated with stimulation of GLUT1 and GLUT4 expression, activation of NOX4, oxidative stress, inflammation, and apoptosis. Acute KLF5 inhibition during reperfusion constitutes a novel therapeutic approach against myocardial ischaemia/reperfusion injury.

The term cardiac amyloidosis (CA) refers to the accumulation of extracellular amyloid deposits in the heart because of different conditions often affecting multiple organs including brain, kidney and liver. Notably, cardiac involvement significantly impacts prognosis of amyloidosis, with cardiac biomarkers playing a pivotal role in prognostic stratification. Therapeutic management poses a challenge due to limited response to conventional heart failure therapies, necessitating targeted approaches aimed at preventing, halting or reversing amyloid deposition. Mechanisms underlying organ damage in CA are multifactorial, involving proteotoxicity, oxidative stress, and mechanical interference. While the role of inflammation in CA remains incompletely understood, emerging evidence suggests its potential contribution to disease progression as well as its utility as a therapeutic target. This review reports on the cardiac involvement in systemic amyloidosis, its prognostic role and how to assess it. Current and emerging therapies will be critically discussed underscoring the need for further efforts aiming at elucidating CA pathophysiology. The emerging evidence suggesting the contribution of inflammation to disease progression and its prognostic role will also be reviewed possibly offering insights into novel therapeutic avenues for CA.

Empagliflozin treatment before acute myocardial infarction mainly targets the endothelial cell transcriptome. Empagliflozin treatment before and after myocardial infarction decreased no reflow and microvascular injury, leading to reduced infiltration of inflammatory cells, reduced infarct size, and improved cardiac function in mice. In diabetic patients receiving empagliflozin after myocardial infarction, perfused boundary region, flow-mediated dilation, and global longitudinal strain were improved.