Tumor necrosis factor-alpha serum activity during treatment of acute decompensation of cachectic and non-cachectic patients with advanced congestive heart failure

YQWY Decoction Improves Myocardial Remodeling via Activating the IL-10/Stat3 Signaling Pathway

Heart failure (HF) has been known as a global health problem, and cardiac remodeling plays an essential role in the development of HF. We hypothesized that YQWY decoction might exert a cardioprotective effect against myocardium inflammation, fibrosis, and apoptosis via activating the interleukin-10 (IL-10)/Stat3 signaling pathway. To test this hypothesis, the HF model in rats was established by pressure overload through the minimally invasive transverse aortic constriction (MTAC). Echocardiography was performed to assess the left ventricular function of rats. Myocardial fibrosis in rats was observed by Masson and Picrosirius red staining, and the degree of myocardial apoptosis was detected via TUNEL staining. In addition, expression levels of IL-10, tumor necrosis factor-α (TNF-α), Stat3 (P-Stat3), P65 (P-P65), CD68, collagen I, TGF-β, CTGF, Bax, Bcl-2, cleaved caspase-3, and PARP in rat serum and myocardium samples were examined by ELISA, western blot, and immunohistochemistry, respectively. YQWY decoction treatment significantly improved left ventricular function in HF rats, especially in those of the high-dose group (LVEF%: 51.29 ± 5.876 vs. 66.02 ± 1.264, P < 0.01;, LVFS%: 27.75 ± 3.757 vs. 37.76 ± 1.137, P < 0.01). Furthermore, YQWY decoction markedly inhibited MTAC-induced myocardial fibrosis as evidenced by downregulated collagen I, TGF-β, and CTGF in myocardium and alleviated apoptosis (downregulated caspase-3 and PARP and increased Bcl-2/Bax ratio in cardiomyocytes). In addition, YQWY decoction decreased the level of the proinflammatory cytokine TNF-α in both circulating blood and myocardium and attenuated infiltration of inflammatory cells in heart tissue from HF rats. Most importantly, YQWY decoction suppressed MTAC-induced NF-κB activation and phosphorylated Stat3 by upregulating IL-10 in rat heart tissues. Our study showed that YQWY decoction could attenuate MTAC-induced myocardial inflammation, fibrosis, apoptosis, and reverse the impairment of cardiac function in rats by activating the IL-10/Stat3 signaling pathway and improving myocardium remodeling. Our findings suggested a therapeutic potential of YQWY decoction in HF.

Depression in heart failure: Intricate relationship, pathophysiology and most updated evidence of interventions from recent clinical studies

Heart failure (HF) is a burgeoning chronic health condition affecting more than 20million people worldwide. Patients with HF have a significant (17.1%) 30-day readmission rate, which invites substantial penalty in payment to hospitals from Centers for Medicare and Medicaid Services, as per the newly introduced Hospital Readmissions Reduction Program. Depression is one of the important risk factors for readmission in HF patients. It has a significant prevalence in patients with HF and contributes to the overall poor quality of life in them. Several behavioral (smoking, obesity, lack of exercise and medication noncompliance) and pathophysiological factors (hypercortisolism, elevated inflammatory biomarkers, fibrinogen, and atherosclerosis) have been found responsible for the adverse outcome in patients with HF and concomitant depression. Hippocampal volume loss noted in patients with acute HF exacerbations may contribute to the development of depressive symptoms in them. Screening for depression in HF patients continues to be challenging due to a considerable overlap in symptoms. Published trials on the use of antidepressants and cognitive behavioral therapy (CBT) have shown variable outcomes. Newer modalities like internet-based CBT have been tried in small studies, with promising results. A recent meta-analysis observed the beneficial role of aerobic exercise training in patients with HFrEF. Future long-term prospective studies may contribute to the formulation of a detailed screening and management guideline for patients with HF and depression. Our review is aimed to summarize the intricate relationship between depression and heart failure, with respect to their epidemiology, pathophysiological aspects, and optimal management approach.

A meta-analysis of proinflammatory cytokines in chronic heart failure

BACKGROUND

Previous studies suggested that inflammation was involved in chronic heart failure (CHF), but their sample sizes were small.

OBJECTIVE

To summarise the clinical cytokine data systematically and emphasise the importance of proinflammatory cytokines in the pathogenesis of CHF, we conducted a meta-analysis of relevant literatures.

METHODS

Articles about cytokines and CHF were searched in Pubmed, EMBASE, Cochrane Library, Chinese National Knowledge Infrastructure and Chinese Wanfang Database. The pooled effects were measured by weighted mean difference (MD) and 95% CI, which were calculated by RevMan 5.1 software.

RESULTS

Finally, a total of 28 studies were included. Compared with normal control subjects, concentrations of tumour necrosis factor-α (TNF-α), interleukin-6 (IL-6), IL-1β and C reactive protein (CRP) in the peripheral blood in CHF patients are significantly increased. The overall MDs with 95% CIs for TNF-α, IL-6, CRP and IL-1β were 2.59 pg/ml (2.14∼3.05, p<0.00001), 5.49 pg/mL (4.68∼6.29, p<0.00001), 11.45 mg/dL (7.68∼15.23, p<0.00001) and 0.11 pg/mL (0.09∼0.14, p<0.00001). The mortality of elevated IL-6 group was significantly higher than control group (OR=6.73, 95% CI 2.39∼18.93, p=0.0003).

CONCLUSIONS

Concentrations of TNF-α, IL-6, IL-1β and CRP are significantly higher in CHF patients than in control subjects. Proinflammatory cytokines play an import role in the pathogenesis of CHF.

How can we cure a heart "in flame"? A translational view on inflammation in heart failure

The prevalence of chronic heart failure is still increasing making it a major health issue in the 21st century. Tremendous evidence has emerged over the past decades that heart failure is associated with a wide array of mechanisms subsumed under the term “inflammation”. Based on the great success of immuno-suppressive treatments in auto-immunity and transplantation, clinical trials were launched targeting inflammatory mediators in patients with chronic heart failure. However, they widely lacked positive outcomes. The failure of the initial study program directed against tumor necrosis factor-α led to the search for alternative therapeutic targets involving a broader spectrum of mechanisms besides cytokines. We here provide an overview of the current knowledge on immune activation in chronic heart failure of different etiologies, summarize clinical studies in the field, address unresolved key questions, and highlight some promising novel therapeutic targets for clinical trials from a translational basic science and clinical perspective.

Short term effects of milrinone on biomarkers of necrosis, apoptosis, and inflammation in patients with severe heart failure

INTRODUCTION

Inotropes are associated with adverse outcomes in heart failure (HF), raising concern they may accelerate myocardial injury. Whether biomarkers of myocardial necrosis, inflammation and apoptosis change in response to acute milrinone administration is not well established.

METHODS

Ten patients with severe HF and reduced cardiac output who were to receive milrinone were studied. Blood samples were taken just before initiation of milrinone and after 24 hours of infusion. Dosing was at the discretion of the patient's attending physician (range 0.25-0.5 mcg/kg/min). Plasma measurements of troponin, myoglobin, N-terminal-pro-BNP, interleukin-6, tumor necrosis factor-alpha, soluble Fas, and soluble Fas-ligand were performed at both time points.

RESULTS

Troponin was elevated at baseline in all patients (mean 0.1259 +/- 0.17 ng/ml), but there was no significant change after 24 hours of milrinone (mean 0.1345 +/- 0.16 ng/ml, p = 0.44). There were significant improvements in interleukin-6, tumor necrosis factor-alpha, soluble Fas, and soluble Fas-ligand (all p < 0.05) indicative of reduced inflammatory and apoptotic signaling compared to baseline.

CONCLUSION

In conclusion, among patients with severe HF and low cardiac output, ongoing myocardial injury is common, and initiation of milrinone did not result in exacerbation of myocardial injury but instead was associated with salutary effects on other biomarkers.

Generating scientific models of knowledge using arcs

BACKGROUND

Systematic approaches are needed to review literature on nutrition in heart failure for its scientific merit, relevance, and usefulness and identify directions for future research.

OBJECTIVES

To evaluate the feasibility of arcs (J.R.G., Indianapolis, Indiana), a computer program for managing data from literature and modeling knowledge, the objectives were to conduct an integrative review of 10 studies of nutrition in heart failure and generate scientific models of knowledge using arcs.

METHODS

A unit of knowledge in arcs is 2 variables linked by a statistical relationship. The computer program arcs categorized variables and relationships found in the 10 explanatory observational studies. It also provided a scientific model for further empirical testing.

RESULTS

The computer program arcs aggregated the following: 104 dependent and 93 independent operational variables and 60 associational, 16 predictive, 15 structural, 1 descriptive, and 85 difference relationships. A direct model produced by arcs postulated a structural relationship between cachexia and 18-month mortality, independent of age or New York Heart Association classification, which can be tested as a path theoretical model.

CONCLUSION

The computer program arcs appeared to be feasible for conducting an integrative review of nutrition in heart failure. A larger, representative set of literature will enable generation of knowledge and identification of gaps and inconsistencies in findings.

Cytokines and acute heart failure

In patients with chronic heart failure, ongoing myocardial injury partially results from activation of the inflammatory system, with production and release of proinflammatory cytokines, activation of the complement system, production of autoantibodies, overexpression of major histocompatibility complex molecules, and expression of adhesion molecules that may perpetuate the inflammatory state. Acute decompensated heart failure modifies the course of chronic heart failure and worsens outcomes via a combination of potential mechanisms, including neurohormonal activation, apoptosis, and the inflammatory cascade. Proinflammatory cytokines, including tumor necrosis factor-alpha and interleukin-6, play a pathogenetic role in chronic heart failure, and anti-inflammatory immune therapy is currently under investigation. In acute decompensation of chronic heart failure, the change in the inflammatory cytokine activation cascade is less clear. Larger investigational studies are needed to assess the exact roles of circulating and intracardiac cytokines in this particular patient population.

Depression in Heart Failure

This article describes a meta-analysis of published associations between depression and heart failure (HF) in regard to 3 questions: 1) What is the prevalence of depression among patients with HF? 2) What is the magnitude of the relationship between depression and clinical outcomes in the HF population? 3) What is the evidence for treatment effectiveness in reducing depression in HF patients? Key word searches of the Medline and PsycInfo databases, as well as reference searches in published HF and depression articles, identified 36 publications meeting our criteria. Clinically significant depression was present in 21.5% of HF patients, and varied by the use of questionnaires versus diagnostic interview (33.6% and 19.3%, respectively) and New York Heart Association-defined HF severity (11% in class I vs. 42% in class IV), among other factors. Combined results suggested higher rates of death and secondary events (risk ratio = 2.1, 95% confidence interval 1.7 to 2.6), trends toward increased health care use, and higher rates of hospitalization and emergency room visits among depressed patients. Treatment studies generally relied on small samples, but also suggested depression symptom reductions from a variety of interventions. In sum, clinically significant depression is present in at least 1 in 5 patients with HF; however, depression rates can be much higher among patients screened with questionnaires or with more advanced HF. The relationship between depression and poorer HF outcomes is consistent and strong across multiple end points. These findings reinforce the importance of psychosocial research in HF populations and identify a number of areas for future study.

Nutritional strategy in the management of heart failure in adults

The incidence of congestive heart failure (CHF) is increasing in Westernized countries, and patients with CHF experience poor quality of life (functional impairment, high hospitalization rate and high mortality). Malnutrition occurring during the course of CHF is referred to as cardiac cachexia and is associated with higher mortality independent of the severity of CHF. Cardiac cachexia involving a loss of more than 10% of lean body mass can clinically be defined as a bodyweight loss of 7.5% of previous dry bodyweight in a period longer than 6 months. The energy requirements of patients with CHF, whether cachectic or not, are not noticeably modified since the increase in resting energy expenditure is compensated by a decrease in physical activity energy expenditure. Malnutrition in CHF has been ascribed to neurohormonal alterations, i.e. anabolic/catabolic imbalance and increased cytokine release. Anorexia may occur, particularly during acute decompensation of CHF. Function is impaired in CHF, because of exertional dyspnea and changes in skeletal muscle. Decreased exercise endurance seems to be related to decreased mitochondrial oxidative capacities and atrophy of type 1 fibers, which are attributed to alteration in muscle perfusion and are partially reversible by training. Malnutrition could also impair muscle function, because of decreased muscle mass and strength associated with decreased glycolytic capacities and atrophy of type 2a and 2b fibres. With respect to the putative mechanisms of cardiac cachexia, anabolic therapy (hormones or nutrients) and anticytokine therapy have been proposed, but trials are scarce and often inconclusive. In surgical patients with CHF, perioperative (pre- and postoperative) nutritional support has been shown to be effective in reducing the mortality rate. Long term nutritional supplementation trials in patients with CHF and cachexia are thus required to establish recommendations for the nutritional management of patients with CHF.

Effects of levosimendan on circulating pro-inflammatory cytokines and soluble apoptosis mediators in patients with decompensated advanced heart failure

This randomized, placebo-controlled trial showed that levosimendan administration causes a significant reduction of circulating proinflammatory cytokine interleukin-6 and soluble apoptosis mediators, such as soluble Fas and Fas ligand in patients with decompensated heart failure. These immunomodulatory effects may lead to improvement of symptoms and echocardiographic markers of cardiac contractile performance in these patients.

Cytokines and anti-cytokine therapeutic approaches to chronic heart failure

Recent investigations have shown that, in addition to neurohormonal system overactivation, another class of biologically active molecules, termed cytokines, is also overexpressed in the setting of chronic heart failure and participates actively in the progression of the syndrome. In this article, we present recent experimental and clinical data describing the pathophysiological role of cytokines in left ventricular remodeling, endothelial dysfunction, and peripheral myopathy characterizing the progression of chronic heart failure, as well as novel therapeutic approaches aimed at attenuating the deleterious effects of cytokines on the cardiovascular system.

The effect of high dose digoxin on cytokines in healthy dogs

BACKGROUND

Tumor necrosis factor (TNF)-alpha and interleukin (IL)-1beta are pro-inflammatory cytokines, causing myocardial dysfunction and a negative inotropic effect. The drugs used to treat heart failure affect the production of cytokines. Digoxin, on which this study was focused, is one of the drugs for the treatment of heart failure.

AIM

The present study was designed to examine the early effects of high doses of digoxin on the production of cytokines in healthy dogs.

METHODS

Digoxin was given parenterally to dogs at 0.15 mg/kg. IL-1beta and TNF-alpha production and levels of digoxin in the serum were measured 0, 12, 24, 48, and 72 h following administration of digoxin.

RESULTS

As the levels of serum digoxin taken at 12, 24, 48, and 72 h of administration were considered significantly high compared with preceding values (p < 0.001), no notable change in serum IL-1beta and TNF-alpha levels was observed.

CONCLUSIONS

These results suggest that high doses of digoxin do not cause a significant cytokine production in heart muscle in the early phase.

Captopril-impaired production of tumor necrosis factor-alpha-induced interleukin-1beta in human monocytes is associated with altered intracellular distribution of nuclear factor-kappaB

We evaluated the effects of the angiotensin-converting enzyme (ACE) inhibitor captopril on pathways for monocyte production of interleukin (IL)-1beta in vitro. Human monocytes were treated with captopril and stimulated with tumor necrosis factor (TNF)-alpha or lipopolysaccharide. Captopril caused a dose-dependent reduction of TNF-alpha induced IL-1beta. LPS-induced IL-1beta generation was not reduced by the ACE inhibitor. Pro-IL-1beta concentrations followed the same pattern as that for mature IL-1beta when monocytes were preincubated with captopril. Also, IL-1beta mRNA concentrations were reduced by captopril pretreatment in parallel with IL-1beta. We sought to determine whether captopril affected the nuclear factor (NF)-kappaB complex in monocytic cells. We found that the translocation of the p-65 component of NF-kappaB to the nucleus was inhibited by captopril. Thus captopril reduced TNF-alpha-induced IL-1beta and IL-1betamRNA synthesis in monocytes, in vitro, probably through interference with NF-kappaB activation of the IL-1beta gene. These results support the hypothesis that captopril has immunomodulating properties.

The enhanced plasma levels of soluble tumor necrosis factor receptors (sTNF-R1; sTNF-R2) and interleukin-10 (IL-10) in patients suffering from chronic heart failure are reversed in patients treated with beta-adrenoceptor antagonist

1 Cytokines may parallel or regulate the beneficial effects of beta-adrenoceptor antagonist treatment observed in chronic heart failure (CHF) patients. Therefore, this study was performed in order to investigate alterations of cytokine levels in beta-blocker-treated patients suffering from CHF. 2 We investigated plasma cytokine levels in eight healthy controls and 12 CHF patients. The patients were treated with standard medication (CHFstd) or with standard medication and additional beta1-blocker metoprolol (CHFmet). Interleukin-(IL)-1alpha, IL-1beta, IL-1 receptor antagonist (IL-1ra), IL-2, IL-6, IL-8, IL-10, tumor necrosis factor-alpha (TNF), soluble TNF receptor type 1 (sTNF-R1), sTNF-R2, and sCD14 were measured by ELISA. 3 IL-1alpha and IL-1beta were not detectable in any of the tested groups. IL-2, TNF, or sCD14 were not altered as compared with healthy control subjects. CHFstd patients expressed enhanced IL-1ra, IL-6, IL-8, IL-10, sTNF-R1 and sTNF-R2. In CHFmet patients IL-1ra, IL-6 and IL-8 remained at the same level. In contrast, sTNF-R1 levels were significantly reduced, although not to control, whereas the sTNF-R2 and IL-10 were reduced to control levels. 4 The cAMP levels of mononuclear cells--recalculated for the patients included in this study from previous work [Werner et al. (2001). Basic Res. Cardiol., 96, 290]--correlated inversely with the sTNF-R2 data (Pearson, r = -0.46; P = 0.041; Spearman, r = -0.64, P = 0.002). 5 The present data indicate an interaction of the neurohumoral and the cytokine system in CHF patients at the cAMP level. Thus, measurement and correlation of sTNF-R2 and cAMP may provide a tool useful during investigation of beta-blocker therapy.

Heart failure and neuroendocrine activation: diagnostic, prognostic and therapeutic perspectives

The important neuroendocrine systems involved in heart failure are reviewed with special emphasis on their possible role in pathophysiology and their relation to prognostic and diagnostic information. Plasma levels of noradrenaline (NA), renin, vasopressin, endothelin-1, atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP) and tumour necrosis factor-alpha (TNF-alpha) are all elevated in heart failure. Activity of the sympathetic nervous system as reflected by NA is correlated to mortality and seems to possess independent prognostic information. Several studies have now documented the beneficial effect of beta-blockade in chronic heart failure (CHF). Renin seems to be a poor prognostic marker in CHF possibly because of the interference with diuretic treatment, angiotensin converting enzyme (ACE)-inhibitors and angiotensin II antagonist, and probably also because of the significance of tissue renin-angiotensin system (RAS), poorly reflected by plasma renin. On the other hand, several large-scale trials with ACE-inhibitors and angiotensin II antagonists have demonstrated reduced mortality and morbidity in CHF. Plasma vasopressin does not seem to possess prognostic information but testing of non-peptide antagonists is ongoing. Endothelin-1 seems to have independent prognostic information and endothelin receptor antagonists may represent a therapeutic possibility. The natriuretic peptides ANP and BNP are correlated to prognosis and possess independent information. Brain natriuretic peptide and N-terminal ANP seem to increase early, i.e. in asymptomatic heart failure. Plasma BNP being more stable than ANP is therefore a promising measure of left ventricular dysfunction. Increase in ANP and BNP, potentially beneficial, may be achieved by administration of neutral endopeptidase inhibitors, at present an unsettled therapeutic possibility. Several cytokines are increased in heart failure and especially TNF-alpha has drawn attention. Experimental studies suggest that TNF-alpha is important in the pathophysiology of heart failure and preliminary studies indicate that inhibition of TNF-alpha seems to be a possible therapeutic approach. Thus, neuroendocrine markers seem to (i) have a role in diagnosis and classification of heart failure, (ii) be useful in providing a 'neuroendocrine profile' which enlightens different aspects of heart failure, and therefore (iii) in the future probably will be valuable in the choice of medical treatment of the individual patient. In addition to beta-blockers, ACE-inhibitors and angiotensin II antagonists several new drugs based on neuroendocrine modification are on their way and might become important in the future.

NF-kappaB mediates the protein loss induced by TNF-alpha in differentiated skeletal muscle myotubes

Nuclear factor-kappaB (NF-kappaB) regulates the transcription of a variety of genes involved in immune responses, cell growth, and cell death. However, the role of NF-kappaB in muscle biology is poorly understood. We recently reported that tumor necrosis factor-alpha (TNF-alpha) rapidly activates NF-kappaB in differentiated skeletal muscle myotubes and that TNF-alpha acts directly on the muscle cell to induce protein degradation. In the present study, we ask whether NF-kappaB mediates the protein loss induced by TNF-alpha. We addressed this problem by creating stable, transdominant negative muscle cell lines. C2C12 myoblasts were transfected with viral plasmid constructs that induce overexpression of mutant I-kappaBalpha proteins that are insensitive to degradation via the ubiquitin-proteasome pathway. These mutant proteins selectively inhibit NF-kappaB activation. We found that differentiated myotubes transfected with the empty viral vector (controls) underwent a drop in total protein content and in fast-type myosin heavy-chain content during 72 h of exposure to TNF-alpha. In contrast, total protein and fast-type myosin heavy-chain levels were unaltered by TNF-alpha in the transdominant negative cell lines. TNF-alpha did not induce apoptosis in any cell line, as assessed by DNA ladder and annexin V assays. These data indicate that NF-kappaB is an essential mediator of TNF-alpha-induced catabolism in differentiated muscle cells.