The role of hypertrophy and growth factors in heart failure

Progranulin deficiency exacerbates cardiac remodeling after myocardial infarction

Myocardial infarction (MI) is a lethal disease that causes irreversible cardiomyocyte death and subsequent cardiovascular remodeling. We have previously shown that the administration of recombinant progranulin (PGRN) protects against myocardial ischemia and reperfusion injury. However, the post-MI role of PGRN remains unclear. In the present study, we investigated the effects of PGRN deficiency on cardiac remodeling after MI. Wild-type and PGRN-knockout mice were subjected to MI by ligation of the left coronary artery for histological, electrophysiological, and protein expression analysis. Cardiac macrophage subpopulations were analyzed by flow cytometry. Bone marrow-derived macrophages (BMDMs) were acquired and treated with LPS + IFN-γ and IL-4 to evaluate mRNA levels and phagocytic ability. PGRN expression was gradually increased in the whole heart at 1, 3, and 7 days after MI. Macrophages abundantly expressed PGRN at the border areas at 3 days post-MI. PGRN-knockout mice showed higher mortality, increased LV fibrosis, and severe arrhythmia following MI. PGRN deficiency increased the levels of CD206 and MerTK expression and macrophage infiltration in the infarcted myocardium, which was attributed to a larger subpopulation of cardiac CCR2+ Ly6Clow CD11b+ macrophages. PGRN-deficient BMDMs exhibited higher TGF-β, IL-4R, and lower IL-1β, IL-10 and increased acute phagocytosis following stimulation of LPS and IFN-γ. PGRN deficiency reduced survival and increased cardiac fibrosis following MI with the induction of abnormal subpopulation of cardiac macrophages early after MI, thereby providing insight into the relationship between properly initiating cardiac repair and macrophage polarization after MI.

Histologic evaluation of therapeutic responses in ischemic myocardium elicited by dual growth factor delivery from composite glycosaminoglycan hydrogels

In this project, the ability of dual growth factor-preloaded, silk-reinforced, composite hyaluronic acid-based hydrogels to elicit advantageous histologic responses when secured to ischemic myocardium was evaluated in vivo. Reinforced hydrogels containing both Vascular Endothelial Growth Factor (VEGF) and Platelet-derived Growth Factor (PDGF) were prepared by crosslinking chemically modified hyaluronic acid and heparin with poly(ethylene glycol)-diacrylate around a reinforcing silk mesh. Composite patches were sutured to the ventricular surface of ischemic myocardium in Sprague-Dawley rats, and the resulting angiogenic response was followed for 28 days. The gross appearance of treated hearts showed significantly reduced ischemic area and fibrous deposition compared to untreated control hearts. Histologic evaluation showed growth factor delivery to restore myofiber orientation to pre-surgical levels and to significantly increase elicited microvessel density and maturity by day 28 in infarcted myocardial tissue (p < 0.05). In addition, growth factor delivery reduced cell apoptosis and decreased the density of elicited mast cells and both CD68+ and anti-inflammatory CD163+ macrophages. These findings suggest that HA-based, dual growth factor-loaded hydrogels can successfully induce a series of beneficial responses in ischemic myocardium, and offer the potential for therapeutic improvement of ischemic myocardial remodeling.

Growth Hormone and Insulin-like Growth Factor 1: New Endocrine Therapies in Cardiology?

The hormones growth hormone (GH) and insulin-like growth factor 1 (IGF-1) play a dominant role in whole body growth and metabolism. This is reflected in the use of human GH (hGH) in GH-deficient children to stimulate growth and in GH-deficient adults to reduce visceral fat mass. Recent data suggest that hGH may improve cardiac function in patients with heart failure, so there is current interest in methods to raise GH-IGF levels, including the testing of agents that release GH from the pituitary, administering IGF-1, and most recently, long-acting formulations of hGH. It is hoped that this ongoing integration of cardiology and endocrinology will uncover the pathophysiology of some cardiovascular diseases and yield new treatments based on the hormones of the GH axis. (Trends Cardiovasc Med 1997;7:264-268). © 1997, Elsevier Science Inc.

Increased IGF1 levels in relation to heart failure and cardiovascular mortality in an elderly population: impact of ACE inhibitors

OBJECTIVE

There are conflicting results regarding the association of circulating IGF1 with cardiovascular (CV) morbidity and mortality. We assessed the relationship between IGF1 levels and heart failure (HF), ischemic heart disease (IHD), and CV mortality in an elderly population taking into account the possible impact of angiotensin converting enzyme (ACE) inhibitors.

DESIGN AND METHODS

A total of 851 persons aged 66-81 years, in a rural Swedish municipality, were subjected to medical history, clinical examination, electrocardiography, echocardiography, and fasting plasma samples. They were then followed for 8 years.

RESULTS AND CONCLUSION

Patients on ACE inhibitors had higher IGF1 levels compared with those without ACE inhibitors. In patients on ACE inhibitors, higher IGF1 values were found in patients with an ejection fraction (EF) <40% compared with EF ≥40%, in patients with higher proBNP levels in quartile 4 vs 1, and in patients with IHD when compared to those without ACE inhibitors (P<0.001). In patients without ACE inhibitors, no relationship was found between IGF1 levels and HF or IHD. In multivariate regression, only ACE inhibitors, ECG changes characteristic for IHD, and gender had a significant impact on IGF1. Patients with higher IGF1 levels in quintiles 4 and 5 compared to quintiles 1 and 2 had a 50% higher risk for CV death (P=0.03). This was significant after adjustment for well-known CV risk factors and ACE inhibitors (P=0.03).

CONCLUSIONS

Our results show that treatment with ACE inhibitors in an elderly population is associated with increased IGF1 levels, especially in patients with impaired cardiac function or IHD. High IGF1 levels tend to be associated with an increased risk for CV mortality.

The GH/IGF-1 Axis and Heart Failure

The growth hormone (GH)/insulin-like growth factor 1 (IGF-1) axis regulates cardiac growth, stimulates myocardial contractility and influences the vascular system. The GH/IGF-1 axis controls intrinsic cardiac contractility by enhancing the intracellular calcium availability and regulating expression of contractile proteins; stimulates cardiac growth, by increasing protein synthesis; modifies systemic vascular resistance, by activating the nitric oxide system and regulating non-endothelial-dependent actions. The relationship between the GH/IGF-1 axis and the cardiovascular system has been extensively demonstrated in numerous experimental studies and confirmed by the cardiac derangements secondary to both GH excess and deficiency. Several years ago, a clinical non-blinded study showed, in seven patients with idiopathic dilated cardiomyopathy and chronic heart failure (CHF), a significant improvement in cardiac function and structure after three months of treatment with recombinant GH plus standard therapy for heart failure. More recent studies, including a small double-blind placebo-controlled study on GH effects on exercise tolerance and cardiopulmonary performance, have shown that GH benefits patients with CHF secondary to both ischemic and idiopathic dilated cardiomyopathy. However, conflicting results emerge from other placebo-controlled trials. These discordant findings may be explained by the degree of CHF-associated GH resistance. In conclusion, we believe that more clinical and experimental studies are necessary to exactly understand the mechanisms that determine the variable sensitivity to GH and its positive effects in the failing heart.

Insulin signaling pathways and cardiac growth

The development, growth, function and metabolism of the heart are regulated by extracellular growth factors, cytokines and ligands. In this review, the role of insulin and insulin-like growth factors in the regulation of cardiac growth will be discussed. In addition, the role of insulin- and insulin-like growth factor-stimulated intracellular signaling proteins in cardiac growth will be reviewed.

Growth hormone therapy in heart failure: a novel therapy worthy of further consideration?

Despite the improvements in survival with angiotensin-converting enzyme inhibitors and beta-blockers, the clinical events for patients with heart failure remain elevated. New therapies for heart failure are required to improve the functional capacity, quality of life and prognosis. Growth hormone exerts both direct and indirect effects on cardiac structure and function. Experimental models of heart failure and small studies have demonstrated significant improvements in cardiac function, haemodynamical parameters, functional capacity and quality of life. The results from randomised controlled studies have been mixed with others showing benefit and some that do not. The randomised studies showing benefit consistently used growth hormone every other day. Further studies are needed to assess the potential role of this adjuvant therapy in patients with heart failure.

Molecular determinants of the physiological adaptation to stress in the cardiomyocyte: a focus on AKT

Cardiomyocytes (CMCs) adapt to physiological or pathological stimuli by undergoing molecular changes which differentiate according to the specificity of the stimulus and eventually generate a phenotype with peculiar molecular characteristics. Here, we review the literature on the molecular mechanisms activated in the CMC during physiologic adaptation to stress, as opposed to maladaptation. The critical role of the IGF-1 receptor/PI3K/Akt signaling pathway during this process is described, including effector targets regulating inotropism and cell size.

Regulation of Cell Size and Contractile Function by AKT in Cardiomyocytes

AKT is a serine-threonine kinase involved in several different cellular functions, including the control of cell size and the regulation of survival and metabolism. Many studies have demonstrated that AKT also plays a critical role in the homeostasis of the cardiomyocyte. In these cells, AKT is activated by upstream molecules such as beta-adrenergic receptor, insulin-like growth factor-1 or insulin receptor, through PI3K alpha; whereas its activation is inhibited by the PTEN molecule. Downstream targets of AKT in the cardiomyocyte include glycogen-synthase kinase-3 beta and S6 kinase. Major effects of AKT activation in the cardiomyocyte are increase in cell size, prevention of apoptosis, and regulation of glucose metabolism. Interestingly, the AKT-dependent hypertrophic pathway is distinct from that activated by MAPKs. In fact, overexpression of AKT does not lead to MAPK activation. Our group has shown, moreover, that AKT exerts a positive effect on both inotropism and relaxation. In fact, mice overexpressing the E40K mutant of AKT in the heart showed improved cardiac function. Thus, AKT increases both cell size through the S6 kinase pathway and inotropism through the functional regulation of critical Ca(2+)-handling proteins. Therefore, AKT is a critical mediator of physiological hypertrophy.

Growth hormone therapy in heart failure: where are we now?

Despite improvement in survival with angiotensin-converting enzyme inhibitors and beta blockers, clinical events for patients with heart failure remain elevated. New therapies for heart failure are needed to improve functional capacity, quality of life, and prognosis. Growth hormone exerts direct and indirect effects on cardiac structure and function. Experimental models of heart failure and small studies have demonstrated significant improvements in cardiac function, hemodynamic parameters, functional capacity, and quality of life. Despite the lack of benefit demonstrated in small, short-term, randomized clinical trials, further studies are needed to assess the potential role of this adjuvant therapy in heart failure patients.

Effects of early treatment with growth hormone on infarct size, survival, and cardiac gene expression after acute myocardial infarction

OBJECTIVE

This study examined the effects of growth hormone (GH) on infarct size, survival, and cardiac gene expression in rats with acute myocardial infarction.

DESIGN

Animals randomly received sc injection of either saline vehicle (n = 98) or GH (2mg/kg/day, n = 105) for 14 days commencing the day of left coronary artery ligation. Infarct size was determined by morphometric analysis at the time of death or at 52 weeks post-surgery. Gene expression was analyzed by real-time RT-PCR after 2-week treatment.

RESULTS

GH decreased infarct size by 18% (P < 0.01) and increased survival by 36% at 52 weeks. GH also significantly reduced cardiac expression of atrial natriuretic factor, beta-myosin heavy chain, alpha-smooth muscle actin, collagen I, collagen III, fibronectin, and pro-inflammatory cytokines.

CONCLUSIONS

Treatment with GH for 2 weeks beginning on the day of myocardial infarction produced beneficial effects that were associated with reductions in cardiac gene expression symptomatic of pathological remodeling.

Physiologic and pathologic myocardial hypertrophy--physiologic and pathologic regression of hypertrophy?

Hypertrophy of the left ventricle is an adaptive phenomenon of ambiguous biological value. It enables improvement of the heart performance without substantial enhancement of energetic demands. On the other hand, pathologic left ventricular hypertrophy (LVH) is characterized by increased fibrosis, diminished coronary flow reserve and protein remodeling, resulting in increased cardiovascular morbidity and mortality. Achievement of LVH regression is thus considered a principal therapeutic aim. However, the reversal of LVH is a very complex process in which both hemodynamic and non-hemodynamic alterations participate. Reversal of LVH does not mean the re-expression of the original genotype and normalization of myocardial structure and function. It does not guarantee that the heart will be normal in all aspects. Regression of hypertrophy induced by different therapeutic means may exhibit different properties and patterns, with variable biological implications. Physiologic growth stimulators seem to induce LVH without prognostically undesirable alterations. It is a challenge to determine which approach to treatment of hemodynamic overload and concomitant LVH is optimal.

Plasma insulin-like growth factor-1 elevated in mild-to-moderate but not severe heart failure

BACKGROUND

Insulin-like growth factor 1 (IGF-1) promotes favorable cardiac remodeling in heart failure. However, the relation of plasma IGF-1 in patients with various degrees of heart failure is not known.

METHODS

Venous plasma samples were collected from patients with clinically documented heart failure (n = 24) and from control subjects (n = 21) for measurements of IGF-1 levels. In the heart failure group, functional assessment of the physical capacity was determined by means of the New York Heart Association (NYHA) score. Objective determination of ventricular performance was made by transthoracic echocardiographic measurement of left ventricular fractional shortening (FS).

RESULTS

IGF-1 levels were higher in patients with heart failure (mean age, 67 +/- 2 years; 17 men) than in control subjects (age, 71 +/- 2 years; 9 men) (20.2 +/- 2 mU/L, 14.1 +/- 2 mU/L, respectively, P <.05). However, the elevated IGF-1 levels were demonstrated only in patients with mild-to-moderate symptoms (NYHA classes I and II) of heart failure (24.7 +/- 3.3 mU/L, n = 12, P =.005 vs control subjects) but not in patients with severe symptoms (NYHA classes III and IV) (15.7 +/- 2.3 mU/L, n = 12). There was a strong positive correlation between IGF-1 levels and left ventricular FS (%) (r = 0.58, P =.003, n = 24). Adjustments for other potential confounders including age, sex, treatment received, and underlying cause of heart failure did not alter the relation between IGF-1 and left ventricular FS (odds ratio, 2.01; 95% confidence interval, 1.26 to 6.24; P =.01).

CONCLUSIONS

Plasma levels of IGF-1 show distinct variations with the severity of heart failure and may play a vital role in compensated heart failure.

Exogenous growth hormone: a new therapy for dilated cardiomyopathy

Heart failure is an epidemic within the United States and, despite current medical therapy, carries a high mortality rate. Growth hormone and insulin-like growth factor-1 have known direct effects on the cardiovascular system. Improvement in contractility, reduction in wall stress, and increase in cardiac performance have been noted in animal experiments. Furthermore, preliminary data from human trials are encouraging. This report outlines the biology of growth hormone, the experimental and human data to support clinical trials of growth hormone treatment, and the outcome of trials reported to date.

Increased cardiomyocyte apoptosis and changes in proapoptotic and antiapoptotic genes bax and bcl-2 during left ventricular adaptations to chronic pressure overload in the rat

BACKGROUND

Left ventricular hypertrophy (LVH) represents both an adaptive response to increased cardiac work load and a precursor state of heart failure. Recent evidence linked cardiac myocyte death by apoptosis with LVH and heart failure. It remained unclear, however, whether apoptosis participated in the transition from LVH to left ventricular dysfunction (LVD).

METHODS AND RESULTS

Cardiac myocyte apoptotic events and changes in apoptosis-specific genes were studied in a rat model of chronic pressure overload induced by transverse aortic constriction. The changes in left ventricular geometry and function were assessed by echocardiography. Transverse aortic constriction rats progressively developed "concentric" LVH and subsequently, LVD. A similar distribution of LVH and LVD was found 18 weeks after surgery. At this time point, we determined the occurrence of myocyte apoptosis by DNA laddering, in situ DNA TUNEL labeling, and light and electron microscopy. The monitoring of proapoptotic and antiapoptotic genes was determined by Western blot and immunohistochemistry. Our data demonstrated that cardiomyocyte apoptotic events increased from virtually undetectable (in sham-operated controls, SH) to 0.8/10(3) and 1.5/10(3) positive nuclei in LVH and LVD, respectively. Fibrosis also increased in the subendocardial and midwall regions of LVH and LVD rats compared with SH. Expression of the proapoptotic gene bax increased, whereas that of antiapoptotic gene bcl-2 decreased in LVH and LVD compared with SH.

CONCLUSIONS

These data suggest that in response to chronic pressure overload, cardiomyocyte-specific apoptosis contributed to the transition from LVH to LVD. LVH and LVD were accompanied by a dramatic cardiomyocyte upregulation of the proapoptotic gene bax and reduced bcl-2/bax ratio, predisposing cardiomyocytes to apoptosis.

IGF-I in experimental daunorubicin-induced cardiomyopathy in rabbits

1. The occurrence of IGF-I was investigated in rabbits with experimentally daunorubicin-induced cardiomyopathy. IGF-I was measured in the heart, serum, liver and skeletal muscle. 2. A significant increase in the IGF-I was found in the left heart ventricle in daunorubicin cardiomyopathy (152.9 +/- 10.0 ng/g vs 95.1 +/- 4.2 ng/g in the control group). This site of increased IGF-I activity corresponded well with the maximum of morphological changes (dispersed cytolysis of cardiomyocytes mostly without developed subsequent interstitial myofibrosis). 3. The highest levels of IGF-I were present in right and left cardiac atrium (but without significant differences between the groups). Furthermore, in skeletal muscle, the levels of IGF-I in the daunorubicin group (839.0 +/- 142.1 ng/g) were significantly higher in comparison with the control group (482.5 +/- 83.1 ng/g). 4. The level of IGF-I in the left ventricle in the daunorubicin group (but not in the control group) was significantly higher than that in the liver. There were no correlations observed between the levels of IGF-I in the heart and in the serum. 5. The increase in IGF-I concentrations in the left heart ventricle after the administration of daunorubicin may thus reflect possible autocrine/paracrine role of IGF-I in cardiomyopathy.

Angiotensin II blockade followed by growth hormone as adjunctive therapy after experimental myocardial infarction

BACKGROUND

Recombinant human growth hormone (rhGH) has shown beneficial effects on cardiac function after myocardial infarction (MI) in rats. High-dose angiotensin II (AT1) receptor blockade in normal rats inhibited the hypertrophic effect of growth hormone (GH), therefore we investigated whether GH effects after MI would be enhanced by giving it in sequence after remodeling had been inhibited by prior AT1 blockade (losartan, L).

METHODS AND RESULTS

Rats given losartan for 10 weeks after MI followed by rhGH for 2 weeks (2 mg/kg twice a day, GH plus losartan) were compared with rats given losartan for 10 weeks followed by placebo for 2 weeks (placebo plus losartan group) and with untreated controls (n = 17-20/group). Average MI sizes and left ventricular (LV) end diastolic (ED) dimensions (echocardiography) did not differ between groups. In GH and losartan, body weight (BW) was increased but left ventricular weight (LVW)/BW was reduced, and the LV fractional shortening and LV dP/dtmax (catheter tip micromanometer) were increased compared with the control group (20.3 vs 15.4% and 5579 vs 4699 mmHg/s, respectively, P < .05). The cardiac index also was significantly increased. In the placebo plus losartan group, the LVW/BW was also reduced and the cardiac index increased versus controls. Stroke volume was increased in GH plus losartan group compared with both placebo plus losartan and controls, and the systemic vascular resistance was significantly decreased only in the GH plus losartan group. The ED posterior wall thickness (noninfarcted wall) was increased in GH plus losartan compared with both control and placebo plus losartan. Left ventricular end diastolic pressure reduction was not significant in GH plus losartan group versus controls but was reduced in placebo plus losartan group, whereas LV relaxation (tau) was improved in both groups versus control rats. Thus, persistent remodeling effects caused by prior AT1 blockade undoubtedly contributed to some responses, but short-term GH given in sequence after chronic AT1 blockade had favorable actions on the failing heart and peripheral circulation by increasing LV wall thickness with partial reversal of unfavorable remodeling, lowering of vascular resistance, improvement of LV contractility, and enhanced LV systolic function and cardiac index relatively late after experimental MI.

Effects of growth hormone and insulin-like growth factor I in experimental heart failure

These studies suggest that IGF-I and GH have generally favourable effects on the failing heart. They further demonstrate the ability of the severely depressed and failing heart to respond to the trophic and inotropic effects of GH. There is, however, a need for a better understanding of the mechanism of the contractility effect, the character of the hypertrophy observed (whether it is a more favourable type than that secondary to mechanical overload) and the vascular actions, both trophic and vasodilatory. In addition, the degree to which high-dose ACE inhibition or angiotensin II receptor blockade may inhibit some of these effects requires further study. Finally, it is clear that additional experimental studies and clinical trials are needed to investigate the long-term effects of GH on morbidity and mortality in heart failure, as well as the possible side-effects and other actions, such as the potential of GH to enhance skeletal muscle size and strength.