The heart rarely develops cancer, and, at the same time, it lacks regenerative capacity, as cardiomyocytes stop proliferating after birth. This suggests that mechanisms limiting cardiac regeneration may also protect against cancer. In this work, we investigated the role of mechanical load and used in vivo cancer models and ex vivo engineered heart tissues to show that mechanical load reduces cancer cell proliferation in the myocardium. Spatial transcriptomics of human cardiac metastases revealed decreased histone methylation and chromatin compaction. These changes affect chromatin accessibility at proliferation-related loci, with Nesprin-2 identified as a key mechanosensor. Our results uncover how mechanical forces protect the heart from cancer and suggest potential strategies for cancer therapy based on mechanical stimulation.

Abstract Background Access to high-quality clinical data is essential for advancing medical research and developing effective medical statistical and Artificial Intelligence models. However, privacy regulations and logistical barriers often hinder timely access to real-world data. Synthetic data offer a promising solution, preserving the statistical characteristics of original datasets while protecting patient privacy. Objectives This study investigates the use of synthetic data for secondary cardiovascular prevention in patients with dyslipidemia, using two real-world datasets from Centro Cardiologico Monzino. Methods Given the high dimensionality and limited sample size of the datasets, we employed a custom generative framework based on Large Language Models (LLMs). Pre-trained LLMs were fine-tuned on original clinical records to synthesize tabular data replicating source-data distributions. Fine-tuning was performed within the Centro Cardiologico Monzino’s secure infrastructure to ensure data sovereignty. We evaluate clinical utility and privacy using fidelity and privacy metrics, identifying the optimal generative model and benchmarking against traditional anonymization methods. Results Synthetic data achieved a superior trade-off than classically anonymized datasets. Real and synthetic datasets showed strong agreement, with significant distributional differences limited to few variables. Models trained on synthetic data replicated key associations from the original dataset, including therapy modification and creatine phosphokinase as predictors of SAMS, and pharmacological intensity as the main driver of LDL-C reduction. Conclusions Results support the feasibility of using synthetic data as a proxy for real-world datasets in exploratory analyses and model development. Despite slight attenuation of some effect sizes, preserved clinical relationships reinforce the validity of synthetic data in medical research.

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.

IntroductionCardiovascular diseases and their major metabolic risk factors remain the leading contributors to morbidity and mortality in Europe. Despite the growing burden of cardiometabolic conditions and the critical role of early-phase research in drug development, the landscape of Phase I clinical trials in this therapeutic area has not been systematically explored in Europe.MethodsWe analysed Phase I clinical trials registered on ClinicalTrials.gov from inception to December 2024, focusing on five European countries (France, Germany, Italy, Spain, and the United Kingdom). After applying disease-specific filters and excluding duplicates, device and dietary supplement studies, 488 trials were retrieved. Conditions were classified into 12 ICD-11-based disease groups and into two macro-categories: cardiovascular diseases (CVDs) and cardiovascular risk factors (CVRFs).ResultsOf the 488 trials, 35% targeted CVDs and 65% CVRFs. Diabetes mellitus was the most frequently studied condition (48%), followed by obesity (9%) and heart failure (7%). Most trials (84%) were industry-sponsored, with seven companies accounting for one-third of studies. Germany and the United Kingdom conducted the most trials (262 and 170 trials), while Italy the fewest (20). Southern countries focused predominantly on CVDs, whereas northern countries more on CVRFs. Trials involving ATMPs and rare diseases were proportionally more common in Spain and Italy. Overall, 51% of studies enrolled healthy volunteers, though none in Italy.ConclusionSignificant geographic disparities and a declining trend in early-phase cardiometabolic research may weaken Europe’s competitiveness in drug development. Strategic investments in infrastructure, regulatory harmonization, and public-private collaboration are needed to reverse the recent trend.

Duchenne muscular dystrophy (DMD) is a X-linked disease affecting skeletal and cardiac muscle and is caused by mutations in the dystrophin gene (DMD). Patient-derived induced pluripotent stem cells (iPSCs) serve as reliable in vitro disease models. Their genetic correction by CRISPR/Cas9 allows the generation of isogenic controls and holds promises for gene therapy. However, restoring full-length dystrophin, especially when deletions involve multiple exons, constitutes a technological challenge. This study aimed to fully repair the dystrophin gene from a DMD iPSC line carrying the deletion of exons 49–50 and to characterize the rescue of the cardiac phenotype. We developed an innovative CRISPR/Cas9-based approach involving the insertion of coding sequences of the deleted region, at the 3’ of exon 48, thereby generating a single continuous coding sequence encompassing exons 48-49-50. Subsequently, iPSCs were differentiated into cardiomyocytes and cardiac fibroblasts. Cardiac phenotypes were analysed by western blot, immunofluorescence, ELISA, FACS, Ionoptix, 3D engineered heart tissue (EHT) and single-nuclei RNA-seq. The correction of a two-exons DMD gene deletion in Duchenne iPSCs, using CRISPR/Cas9, enabled the re-expression of a stable and functional full-length dystrophin in cardiomyocytes resulting in the rescue of cardiac pathological phenotypes. Edited cardiomyocytes showed improved morphology, reduced release of the cardiomyocytes damage marker troponin I, and decreased ROS production. Moreover, dystrophin restoration enhanced contractility and ameliorated the Ca2+ kinetics. Notably, edited iPSC derived fibroblasts showed reduced pro-fibrotic stimuli response. In parallel, we also observed enhanced functioning of a 3D engineered heart tissue and profound change in the transcriptomic profile in both cardiomyocytes and fibroblasts after the re-expression of full-length dystrophin. We developed an innovative approach that enabled the re-expression of full-length dystrophin in a DMD iPSC line with consequent complete rescue of in vitro DMD cardiac phenotypes. On the long term, these results could lay a foundation for future applications of cell therapy or in vivo CRISPR/Cas9-based intervention to treat DMD.

Messenger RNA (mRNA) is emerging as a new tool for therapeutic intervention, providing a transient, programmable platform for the treatment of complex diseases. Unlike DNA-based therapies, mRNA does not integrate into the genome and is considered more safe. The success of mRNA vaccines, combined with advances in mRNA technology and unmet needs in cardiovascular disease (CVD), has led to increased interest in expanding the use of this technology beyond infectious diseases. However, there are several challenges to overcome, including mRNA stability, delivery efficiency, immunogenicity, and regulatory standardization. This review examines advances in mRNA design, delivery platforms, and therapeutic applications in CVDs, emphasizing the need for a clear regulatory framework to facilitate clinical translation. The establishment of consistent regulatory guidelines will be a critical step in ensuring the safety and efficacy of mRNA-based cardiovascular therapies, potentially facilitating their widespread adoption. The future direction of research in mRNA formulation, personalized medicine approaches, and the refinement of regulatory policies will determine the landscape of next-generation cardiovascular therapeutics.

OBJECTIVE:Aortic valve sclerosis affects 30 % of individuals over 65 and is associated with coronary artery disease, with risk of progression to aortic stenosis. Endothelial dysfunction, mediated by oxidative stress, impaired nitric oxide (NO) signaling, inflammation, and lipoprotein deposition, plays a central role in disease initiation and progression. This study investigated whether a combination of bioactive compounds could counteract these mechanisms and support vascular health. METHODS:The effects of curcuma longa, coenzyme Q10, black garlic, vitamin B1, and vitamin D3 were tested in vitro on aortic valve endothelial cells. Cell viability, reactive oxygen species (ROS), and NO levels were quantified by commercially available kits, while gene expression was analyzed by RNA sequencing. A 4-week prospective pilot clinical study in 10 healthy volunteers without cardiovascular disease evaluated endothelial function and arterial stiffness. RESULTS:The compounds reduced ROS production (>27 %; p < 0.05), enhanced endothelial viability (>33 %; p < 0.05; except curcuma and black garlic), and increased NO production (>6 %; p < 0.05; except black garlic). Beneficial effects were reflected in upregulation of anti-atherosclerotic (GIPR, +0.058 copies per million, CPM; p < 0.05), antioxidant (GADL1, +0.55 CPM; p < 0.001), and anti-inflammatory (IL12A, +0.17 CPM; p < 0.01) genes. Clinically, daily supplementation improved endothelial function in participants found to have pre-existing endothelial dysfunction (p = 0.0336), with 50 % achieving normal levels after 4 weeks, while all subjects exhibited reduced arterial stiffness (p = 0.0016) without hepatic toxicity. CONCLUSIONS:The oral supplementation of the combination of these bioactive compounds improved endothelial function and vascular health, particularly in individuals with endothelial dysfunction, offering potential therapeutic benefits for cardiovascular health.

BACKGROUND:Coronary artery bypass grafting (CABG) is the preferred invasive treatment option for complex coronary artery disease (CAD), bypassing flow-limiting lesions and high-risk plaques (HRP), thereby reducing clinical events. It also provides graft collateralization, preventing cardiac events due to proximal plaque rupture or erosion, and vessel occlusion. This study evaluated the prevalence of HRPs in segments proximal and distal to graft anastomoses and in non-grafted segments, using coronary computed tomography angiography (CCTA) in patients with left main and three-vessel disease enrolled in the FASTTRACK CABG study. METHODS:Coronary segments were categorized as proximal, distal, or non-grafted. Segments ≥1.5 ​mm on CCTA were screened for HRP features: low-attenuation plaque, positive remodelling, spotty calcification, and napkin ring. Minimal lumen area (MLA) and plaque burden at MLA were assessed in segments ≥3 ​mm in diameter. Perivascular adipose tissue attenuation was evaluated in major coronary arteries. RESULTS:In 102 patients, 1767 segments were analyzed: 986 proximal, 348 distal, and 341 non-grafted. HRP prevalence was highest in proximal segments (45.13 ​% vs. 8.33 ​% distal vs. 28.74 ​% non-grafted, p ​< ​0.001). Non-grafted vessels with a Fractional Flow Reserve Computed Tomography (FFRCT) ≥0.80 had High-Risk Plaques (HRPs) in 40.38 ​% of cases, compared to 32.58 ​% for those with an FFRCT <0.80. The prevalence of HRPs between patients or vessels with graft occlusions and those without, was similar. Likewise, there was no significant difference in perivascular fat attenuation between patients and vessels with and without HRP. CONCLUSIONS:In patients undergoing CABG for complex CAD, surgery effectively bypassed most HRPs, however, a substantial proportion remained in non-grafted vessels. TRIAL REGISTRATION:NCT04142021.

Duchenne muscular dystrophy (DMD) is a genetic progressive neuromuscular disorder characterized by early-onset proximal muscle weakness and significant long-term pulmonary and cardiac involvement. Due to the early pharmacological treatments and the wider adoption of non-invasive ventilation, life expectancy has significantly increased in recent years, highlighting the relevance of DMD-related cardiomyopathy and fatal arrhythmias, especially in the late stage of the disease. Current guideline-derived evaluation of sudden cardiac death (SCD) in DMD lacks accuracy, leading to inadequate arrhythmic risk stratification and jeopardized SCD prevention strategies. This review aims to outline these critical issues, proposing an integrative approach encompassing manifold tools such as an imaging-derived systematic and comprehensive evaluation (speckle-tracking echocardiography and magnetic resonance imaging), the electrophysiological study, the 3-dimensional electroanatomic mapping, and a multidimensional clinical examination. This approach might lead to more personalized management along with an effective arrhythmia-prevention strategy aiming to balance clinical care goals, patient expectations, and ethical considerations.

BACKGROUND:Diagnostic concordance among Fractional Flow Reserve derived from computed tomography (FFRCT), and the Quantitative flow ratio (QFR) and Murray's Law-based QFR (μFR) derived from invasive coronary angiography (ICA) is implicitly assumed. METHODS:Coronary CT angiography (CCTA) and ICA were analyzed in a central imaging core lab in this post-hoc imaging sub-study of the FASTTRACK CABG trial that enrolled 114 patients with de-novo three-vessel and/or left-main coronary artery disease. FFRCT, QFR, and μFR were analyzed at corresponding bifurcation points on CCTA and ICA, and virtual pullback pressure gradient index (PPGi) and FFR derivatives (dFFR/ds) were assessed to patho-physiologically categorize the lesion phenotype into diffuse or focal. RESULTS:In 199 vessels, mean distal estimates of FFRCT (0.70), QFR (0.71), and μFR (0.69) were similar (p ​= ​0.127). QFR was significantly higher than FFRCT (p ​< ​0.01) and μFR (p ​< ​0.01) in the main branches of the two most proximal bifurcations. Concordance between FFRCT and QFR, and FFRCT and μFR was 76.3 ​% (kappa ​= ​0.451) and 80.3 ​% (kappa ​= ​0.544), respectively, when using a cut-off of ≤0.80. Concordance in the pathophysiological lesion phenotype (diffuse or focal) as derived from virtual PPGi was poor between FFRCT vs QFR (k ​= ​0.04) and FFRCT vs μFR (k ​= ​0.16). QFR (20.9 ​%) tended to identify focal lesions more frequently than FFRCT (13.4 ​%) and μFR (7.5 ​%). CONCLUSIONS:In the two most proximal bifurcations, QFR values were higher than FFRCT and μFR, resulting in lesion severity being underestimated, which may impact revascularization decisions. The pathophysiological phenotype classification was poorly correlated among FFRCT, QFR, and μFR. TRIAL REGISTRATION NUMBER:NCT04142021.

Cardiomyopathy represents the most important life-limiting condition of Duchenne muscular dystrophy (DMD) patients after the age of 20. Genetic alterations in the DMD gene result in the absence of functional dystrophin protein, leading to skeletal/cardiac muscle impairment. The DMD incidence is one in 5000 live male births. Identifying the genetic background, in addition to DMD disease-causing variants, is one of the unmet needs in understanding the cardiac disease’s pathogenetic mechanisms and its prognostic implications. The clinical scenario is made even more intricate by the difficulty in predicting the onset and progression of cardiomyopathy, as no clear genotype/phenotype correspondence has been found thus far. The evaluation of genes involved in the onset of primary cardiomyopathies could explore the hypothesis that changes in cytoskeletal and sarcomeric protein function are the modulators of ventricular dysfunction in DMD patients. In the last decade, with the advent of next-generation sequencing (NGS) technology, many disease-causing genes and modifiers have been identified. Assessing the genetic origin of the phenotypic variability of the disease in both the onset and progression of cardiomyopathy in DMD would be extremely helpful in managing these patients. This review article aims to spotlight the genetic background associated with Cardiomyopathy in DMD patients toward a more predictive personalized model of care.

Arrhythmogenic cardiomyopathy (ACM) is a cardiac disorder manifesting through electrical and contractile dysfunction of the ventricles, characterized by fibro-fatty substitution of the myocardium. Cardiac mesenchymal stromal cells (CMSCs) are key contributors to this remodeling. In clinical management, several pharmacological approaches address ACM arrhythmias and heart failure, but, to date, none specifically target fibro-adipose replacement. Despite genetic origin, several studies have reported that non-genetic aspects influence ACM phenotype, including epigenetic factors. Little is known about their mechanisms in ACM and their potential therapeutic applications. In this work, we aimed to test whether, by perturbing the epigenetic landscape of ACM CMSCs, we could influence their propensity to fibro-fatty differentiation. We conducted a hypothesis-free screening of 157 epigenetic drugs on CMSCs, isolated from ACM patients. Through fluorescence assays, we evaluated lipid droplet accumulation, collagen deposition, and cell viability. Of the 157 drugs screened, five (splitomicin, suberohydroxamic acid, CPTH6, BVT-948, and PBIT) attenuated adipogenic differentiation of ACM CMSCs, with BVT-948 and CPTH6 also reducing collagen production. Overall, this study identified specific epigenetic drugs that were effective in reducing the fibro-fatty phenotype of ACM stromal cells, thus offering potential for adjunctive therapies in the clinical management of ACM patients.

BACKGROUND:Despite recent significant therapeutic progress, cardiovascular diseases (CVD) remain an unmet clinical, economic, and social burden worldwide. Cell-based therapies have been proposed as therapeutic strategies, however, the overall efficacy was modest. OBJECTIVE:We aimed to fully characterize a novel subpopulation of CD90- mesenchymal cells derived from human heart tissue (hCmPC90-) and evaluate its ability to induce cardiac tissue repair and functional recovery. METHODS:We performed a comprehensive phenotypic characterization of the hCmPC90- by flow cytometry and RNA sequencing. A direct comparison of hCmPC90- with previously clinically tested bone marrow- and cardiac-derived cell types, has been conducted both in vitro by means of various assays of angiogenic potency, and in vivo, by testing the ability to ameliorate left ventricular function in a mouse model of acute myocardial infarction (AMI). RESULTS:hCmPC90- showed distinct surface markers and transcriptional phenotype compared with unselected mesenchymal heart cells (hCmPCs) and the positive CD90 counterpart (hCmPC90+). When human hCmPC90-, hCmPC90+, hCmPC, cardiosphere-derived cells (CDCs), and bone marrow-derived CD34+ cells were functionally tested in vitro, hCmPC90- revealed a superior endothelial differentiation ability, higher anti-inflammatory, cardio-protective capacity, and angiocrine activity. Moreover, hCmPC90- showed specific immune-privileged features. When intramyocardially delivered into infarcted mouse hearts, hCmPC90- outperformed three weeks after injection other clinical-grade cell types, as for left ventricular (LV) function and adverse LV remodeling recovery, infarct size reduction, and vascular density augmentation. CONCLUSION:hCmPC90- shows a superior biological potency which deserves clinical exploitation as an advanced therapy medicinal product in the context of refractory ischemic heart disease.

Arrhythmogenic cardiomyopathy (ACM) is an inherited cardiac disorder that causes sudden cardiac death and progressive heart failure. Besides fibro-fatty replacement and myocyte degenerative changes, inflammatory patchy infiltrates are found in myocardial histological analysis of ACM patients. Inflammatory cells could actively participate in ACM pathogenesis, contributing to the alteration of cardiac microenvironment homeostasis, thus triggering disease evolution. In order to characterize the immune-derived mediators involved in ACM pathogenesis, peripheral blood mononuclear cells from ACM patients were characterized and compared to healthy controls’ ones. Flow cytometry analysis revealed a lower frequency of CD4+ T helper type 1 cells, NK cells, and terminally differentiated CD8+ EMRA+ T cells in ACM patients compared to age-matched controls. In contrast, a higher proportion of effector/memory FOXP3+ CCR4+ CD45RO+ regulatory CD4+ T cells (Treg) were found in ACM patients. Single-cell RNA-seq performed on isolated memory Treg cells (mTreg) from ACM patients and healthy controls identified 6 clusters characterized by specific gene signatures related to tissue repair and immunosuppressive pathways. Notably, interleukin 32 (IL-32) was the most differentially expressed gene in ACM patients mTreg with respect to healthy controls. Treatment of human cardiac mesenchymal stromal cells with recombinant IL-32 in vitro promoted lipid droplet accumulation and collagen deposition, thus identifying IL-32 as a new potential player in the immune-mediated trigger of cardiac fibro-fatty replacement in ACM. Overall, we here provide the first complete characterization of circulating ACM immune cells, revealing an abundance of Treg. The high expression of IL-32 in ACM Treg may contribute to accelerated cardiac remodeling in ACM patients’ hearts.

The current European framework for Advanced Therapy Medicinal Products (ATMPs), which also covers gene therapies, was established in 2007 at the dawn of the biotechnology era in the pharmaceutical sector. However, its inherent limitations have been revealed by the new frontiers enabled by the scientific and technological advances of the past few decades, particularly in the areas of innovative gene therapeutics (e.g., CRISPR/Cas9-RNA complexes), manufacturing technologies, and delivery systems. Here, we contribute to the scientific discussion on how to reduce regulatory uncertainty in the qualification of medicinal products with a different mechanism of action (e.g., editing the host genome or regulating gene expression), and on rationalizing regulatory support and incentives for the most complex therapies in terms of mechanism of action and manufacturing process.

Arrhythmogenic cardiomyopathy (ACM) is an inherited cardiac disorder that predisposes affected individuals, especially young patients, to malignant arrhythmias, sudden cardiac death, and heart failure. The disease is characterized by myocardial atrophy and fibro-fatty replacement, predominantly affecting the right ventricle. Current pharmacological treatments primarily aim to alleviate symptoms by addressing arrhythmias and heart failure. These approaches are often complemented by invasive interventions such as implantable cardioverter defibrillators (ICDs) and radiofrequency ablations. However, none of these strategies effectively halts disease progression, highlighting the urgent need for novel disease-modifying therapies. We recently demonstrated that elevated plasma levels of oxidized low-density lipoprotein (oxLDL) correlate with more advanced stages of ACM in patients. Moreover, treatment with atorvastatin, which reduces oxLDL levels, prevented disease manifestation in a mouse model of ACM. Based on these findings, we hypothesize that statins may attenuate disease progression in ACM patients not only through their lipid-lowering effects, but also via pleiotropic actions such as antioxidant, anti-inflammatory, and autonomic modulation. To test this hypothesis, we designed SEARCH (Statin Effect on ARrhythmogenic CardiomyopatHy), an investigator-initiated, multicenter, prospective, randomized, double-blind, placebo-controlled clinical trial, aimed at evaluating the efficacy of atorvastatin in preventing ACM progression (NCT06922994). A total of 102 patients meeting ACM diagnostic criteria will be enrolled and randomized in a 1:1 ratio to receive either atorvastatin 80 mg/die or placebo for 18 months. The primary outcome will be the change in right ventricular global longitudinal strain, a sensitive echocardiographic measure of ventricular function, from baseline to 18 months. Secondary outcomes will include changes in arrhythmic burden, electrocardiography parameters, additional structural and functional cardiac indices, and circulating biomarkers. Tertiary and exploratory outcomes include the validation of risk scores for ACM progression and the identification of variables predicting the best responders to atorvastatin. Participants will undergo a comprehensive evaluation at baseline, 9 months, and 18 months, including cardiology visits, echocardiography, electrocardiography, blood testing, ICD or loop recorder interrogation, and cardiac magnetic resonance imaging (at enrollment and at 18 months only). Additional safety assessments and telephone follow-ups will be conducted throughout the study to monitor treatment adherence and potential adverse events. The SEARCH trial is expected to generate the first clinical evidence on the efficacy of atorvastatin in slowing ACM progression, thereby addressing a major unmet therapeutic need. The findings will shape the design of future large-scale studies and may pave the way for a novel, disease-modifying treatment strategy to improve outcomes and quality of life for patients with ACM.