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Loeffler DA. Approaches for Increasing Cerebral Efflux of Amyloid-β in Experimental Systems. J Alzheimers Dis 2024:JAD240212. [PMID: 38875041 DOI: 10.3233/jad-240212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024]
Abstract
Amyloid protein-β (Aβ) concentrations are increased in the brain in both early onset and late onset Alzheimer's disease (AD). In early onset AD, cerebral Aβ production is increased and its clearance is decreased, while increased Aβ burden in late onset AD is due to impaired clearance. Aβ has been the focus of AD therapeutics since development of the amyloid hypothesis, but efforts to slow AD progression by lowering brain Aβ failed until phase 3 trials with the monoclonal antibodies lecanemab and donanemab. In addition to promoting phagocytic clearance of Aβ, antibodies lower cerebral Aβ by efflux of Aβ-antibody complexes across the capillary endothelia, dissolving Aβ aggregates, and a "peripheral sink" mechanism. Although the blood-brain barrier is the main route by which soluble Aβ leaves the brain (facilitated by low-density lipoprotein receptor-related protein-1 and ATP-binding cassette sub-family B member 1), Aβ can also be removed via the blood-cerebrospinal fluid barrier, glymphatic drainage, and intramural periarterial drainage. This review discusses experimental approaches to increase cerebral Aβ efflux via these mechanisms, clinical applications of these approaches, and findings in clinical trials with these approaches in patients with AD or mild cognitive impairment. Based on negative findings in clinical trials with previous approaches targeting monomeric Aβ, increasing the cerebral efflux of soluble Aβ is unlikely to slow AD progression if used as monotherapy. But if used as an adjunct to treatment with lecanemab or donanemab, this approach might allow greater slowing of AD progression than treatment with either antibody alone.
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Affiliation(s)
- David A Loeffler
- Department of Neurology, Beaumont Research Institute, Corewell Health, Royal Oak, MI, USA
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2
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Nguyen BA, Afrin S, Yakubovska A, Singh V, Alicea JV, Kunach P, Singh P, Pekala M, Ahmed Y, Fernandez-Ramirez MDC, Hernandez LOC, Pedretti R, Bassett P, Wang L, Lemoff A, Villalon L, Kluve-Beckerman B, Saelices L. ATTRv-V30M Type A amyloid fibrils from heart and nerves exhibit structural homogeneity. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.14.594028. [PMID: 38798361 PMCID: PMC11118387 DOI: 10.1101/2024.05.14.594028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
ATTR amyloidosis is a systemic disease characterized by the deposition of amyloid fibrils made of transthyretin, a protein integral to transporting retinol and thyroid hormones. Transthyretin is primarily produced by the liver and circulates in blood as a tetramer. The retinal epithelium also secretes transthyretin, which is secreted to the vitreous humor of the eye. Because of mutations or aging, transthyretin can dissociate into amyloidogenic monomers triggering amyloid fibril formation. The deposition of transthyretin amyloid fibrils in the myocardium and peripheral nerves causes cardiomyopathies and neuropathies, respectively. Using cryo-electron microscopy, here we determined the structures of amyloid fibrils extracted from cardiac and nerve tissues of an ATTRv-V30M patient. We found that fibrils from both tissues share a consistent structural conformation, similar to the previously described structure of cardiac fibrils from an individual with the same genotype, but different from the fibril structure obtained from the vitreous humor. Our study hints to a uniform fibrillar architecture across different tissues within the same individual, only when the source of transthyretin is the liver. Moreover, this study provides the first description of ATTR fibrils from the nerves of a patient and enhances our understanding of the role of deposition site and protein production site in shaping the fibril structure in ATTRv-V30M amyloidosis.
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Affiliation(s)
- Binh An Nguyen
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Shumaila Afrin
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Anna Yakubovska
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Virender Singh
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Jaime Vaquer Alicea
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Peter Kunach
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Neurology, McGill University, Montreal, Quebec, Canada
| | - Preeti Singh
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Maja Pekala
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Yasmin Ahmed
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Maria del Carmen Fernandez-Ramirez
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Luis O. Cabrera Hernandez
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Rose Pedretti
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Parker Bassett
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Lanie Wang
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Andrew Lemoff
- Department of Biochemistry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Layla Villalon
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Barbara Kluve-Beckerman
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lorena Saelices
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
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Cannie D, Patel K, Protonotarios A, Heenan I, Bakalakos A, Syrris P, Menezes L, Elliott PM. Prevalence of transthyretin cardiac amyloidosis in patients with high-degree AV block. Open Heart 2024; 11:e002606. [PMID: 38538064 PMCID: PMC10982802 DOI: 10.1136/openhrt-2024-002606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 03/12/2024] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVE Transthyretin amyloid cardiomyopathy (ATTR-CM) is an infiltrative cardiac disorder caused by deposition of wild type or mutated transthyretin. As ATTR-CM is associated with conduction disease, we sought to determine its prevalence in patients with idiopathic high-degree atrioventricular (AV) block requiring permanent pacemaker (PPM) implantation. METHODS Consecutive patients aged 70-85 years undergoing PPM implantation for idiopathic high-degree AV block between November 2019 and November 2021 were offered a 3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scan. Demographics, comorbidities, electrocardiographic and imaging data from the time of device implantation were retrospectively collected. RESULTS 39 patients (79.5% male, mean (SD) age at device implantation 76.2 (2.9) years) had a DPD scan. 3/39 (7.7%, all male) had a result consistent with ATTR-CM (Perugini grade 2 or 3). Mean (SD) maximum wall thickness of those with a positive DPD scan was 19.0 mm (3.6 mm) vs 11.4 mm (2.7 mm) in those with a negative scan (p=0.06). All patients diagnosed with ATTR-CM had spinal canal stenosis and two had carpal tunnel syndrome. CONCLUSIONS ATTR-CM should be considered in older patients requiring permanent pacing for high-degree AV block, particularly in the presence of left ventricular hypertrophy, carpal tunnel syndrome or spinal canal stenosis.
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Affiliation(s)
- Douglas Cannie
- University College London, London, UK
- St Bartholomew's Hospital, London, UK
| | - Kush Patel
- University College London, London, UK
- St Bartholomew's Hospital, London, UK
| | | | | | | | | | - Leon Menezes
- University College London, London, UK
- St Bartholomew's Hospital, London, UK
| | - Perry M Elliott
- University College London, London, UK
- St Bartholomew's Hospital, London, UK
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4
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Nguyen BA, Singh V, Afrin S, Singh P, Pekala M, Ahmed Y, Pedretti R, Canepa J, Lemoff A, Kluve-Beckerman B, Wydorski P, Chhapra F, Saelices L. Cryo-EM confirms a common fibril fold in the heart of four patients with ATTRwt amyloidosis. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.08.582936. [PMID: 38496656 PMCID: PMC10942412 DOI: 10.1101/2024.03.08.582936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
ATTR amyloidosis results from the conversion of transthyretin into amyloid fibrils that deposit in tissues causing organ failure and death. This conversion is facilitated by mutations in ATTRv amyloidosis, or aging in ATTRwt amyloidosis. ATTRv amyloidosis exhibits extreme phenotypic variability, whereas ATTRwt amyloidosis presentation is consistent and predictable. Previously, we found an unprecedented structural variability in cardiac amyloid fibrils from polyneuropathic ATTRv-I84S patients. In contrast, cardiac fibrils from five genotypically-different patients with cardiomyopathy or mixed phenotypes are structurally homogeneous. To understand fibril structure's impact on phenotype, it is necessary to study the fibrils from multiple patients sharing genotype and phenotype. Here we show the cryo-electron microscopy structures of fibrils extracted from four cardiomyopathic ATTRwt amyloidosis patients. Our study confirms that they share identical conformations with minimal structural variability, consistent with their homogenous clinical presentation. Our study contributes to the understanding of ATTR amyloidosis biopathology and calls for further studies.
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Affiliation(s)
- Binh An Nguyen
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Virender Singh
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Shumaila Afrin
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Preeti Singh
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Maja Pekala
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Yasmin Ahmed
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Rose Pedretti
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Jacob Canepa
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biochemistry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Andrew Lemoff
- Department of Biochemistry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Barbara Kluve-Beckerman
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Pawel Wydorski
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Farzeen Chhapra
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
| | - Lorena Saelices
- Center for Alzheimer’s and Neurodegenerative Diseases, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Department of Biophysics, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
- Peter O’Donnell Jr Brain Institute, University of Texas Southwestern Medical Center (UTSW), Dallas, TX, USA
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5
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Aimo A, Panichella G, Garofalo M, Gasparini S, Arzilli C, Castiglione V, Vergaro G, Emdin M, Maffei S. Sex differences in transthyretin cardiac amyloidosis. Heart Fail Rev 2024; 29:321-330. [PMID: 37566193 PMCID: PMC10942898 DOI: 10.1007/s10741-023-10339-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 08/12/2023]
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) is a progressive disease characterized by the deposition of abnormal transthyretin protein fibrils in the heart, leading to cardiac dysfunction. Recent evidence suggests that sex differences may play a significant role in various steps of ATTR-CA, including clinical presentation, diagnostic challenges, disease progression, and treatment outcomes. ATTR-CA predominantly affects men, whereas women are older at presentation. Women generally present with a history of heart failure with preserved ejection fraction and/or carpal tunnel syndrome. When indexed, left ventricular (LV) wall thickness is equal, or even increased, than men. Women also have smaller LV cavities, more preserved ejection fractions, and apparently a slightly worse right ventricular and diastolic function. Given the under-representation on women in clinical trials, no data regarding sex influence on the treatment response are currently available. Finally, it seems there are no differences in overall prognosis, even if premenopausal women may have a certain level of myocardial protection. Genetic variations, environmental factors, and hormonal changes are considered as potential contributors to observed disparities. Understanding sex differences in ATTR-CA is vital for accurate diagnosis and management. By considering these differences, clinicians can improve diagnostic accuracy, tailor treatments, and optimize outcomes for both sexes with ATTR-CA.
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Affiliation(s)
- Alberto Aimo
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
| | - Giorgia Panichella
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Manuel Garofalo
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Simone Gasparini
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Paediatric Neurology Unit and Laboratories, Neuroscience Department, Meyer Children's Hospital IRCCS, Florence, Italy
| | | | - Vincenzo Castiglione
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Vergaro
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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Keil L, Berisha F, Ritter S, Skibowski J, Subramanian H, Nikolaev VO, Kubisch C, Woitschach R, Fabritz L, Twerenbold R, Blankenberg S, Weidemann S, Zeller T, Kirchhof P, Reichart D, Magnussen C. Multimodal characterization of dilated cardiomyopathy: Geno- And Phenotyping of PrImary Cardiomyopathy (GrAPHIC). ESC Heart Fail 2024; 11:541-549. [PMID: 37964758 PMCID: PMC10804161 DOI: 10.1002/ehf2.14544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 08/23/2023] [Accepted: 09/15/2023] [Indexed: 11/16/2023] Open
Abstract
AIMS Cardiomyopathies (CMPs) are a heterogeneous group of diseases that are defined by structural and functional abnormalities of the cardiac muscle. Dilated cardiomyopathy (DCM), the most common CMP, is defined by left ventricular dilation and impaired contractility and represents a common cause of heart failure. Different phenotypes result from various underlying genetic and acquired causes with variable effects on disease development and progression, prognosis, and response to medical treatment. Current treatment algorithms do not consider these different aetiologies, due to lack of insights into treatable drivers of cardiac failure in patients with DCM. Our study aims to precisely phenotype and genotype the various subtypes of DCM and hereby lay the foundation for individualized therapy. METHODS AND RESULTS The Geno- And Phenotyping of PrImary Cardiomyopathy (GrAPHIC) is a currently ongoing prospective observational monocentric cohort study that recruits patients with DCM after exclusion of other causes such as coronary artery disease, valvular dysfunction, myocarditis, exposure to toxins, and peripartum CMP. Patients are enrolled at our heart failure outpatient clinic or during hospitalization at the University Hospital Hamburg. Clinical parameters, multimodal imaging and functional assessment, cardiac biopsies, and blood samples are obtained to enable an integrated genomic, functional, and biomarker analysis. CONCLUSIONS The GrAPHIC will contribute to a better understanding of the heterogeneous nature of primary CMPs focusing on DCM and provide improved prognostic approaches and more individualized therapies.
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Affiliation(s)
- Laura Keil
- Department of CardiologyUniversity Heart and Vascular Center Hamburg, University Medical Center Hamburg‐EppendorfHamburgGermany
| | - Filip Berisha
- Department of CardiologyUniversity Heart and Vascular Center Hamburg, University Medical Center Hamburg‐EppendorfHamburgGermany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/LuebeckHamburgGermany
- Institute of Experimental Cardiovascular ResearchUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Stella Ritter
- Department of CardiologyUniversity Heart and Vascular Center Hamburg, University Medical Center Hamburg‐EppendorfHamburgGermany
| | - Johanna Skibowski
- Department of CardiologyUniversity Heart and Vascular Center Hamburg, University Medical Center Hamburg‐EppendorfHamburgGermany
| | - Hariharan Subramanian
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/LuebeckHamburgGermany
- Institute of Experimental Cardiovascular ResearchUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Viacheslav O. Nikolaev
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/LuebeckHamburgGermany
- Institute of Experimental Cardiovascular ResearchUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Christian Kubisch
- Institute of Human GeneticsUniversity Hospital Hamburg‐EppendorfHamburgGermany
| | - Rixa Woitschach
- Institute of Human GeneticsUniversity Hospital Hamburg‐EppendorfHamburgGermany
| | - Larissa Fabritz
- Department of CardiologyUniversity Heart and Vascular Center Hamburg, University Medical Center Hamburg‐EppendorfHamburgGermany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/LuebeckHamburgGermany
- University Centre of Cardiovascular Science, UKE HamburgHamburgGermany
| | - Raphael Twerenbold
- Department of CardiologyUniversity Heart and Vascular Center Hamburg, University Medical Center Hamburg‐EppendorfHamburgGermany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/LuebeckHamburgGermany
- University Centre of Cardiovascular Science, UKE HamburgHamburgGermany
| | - Stefan Blankenberg
- Department of CardiologyUniversity Heart and Vascular Center Hamburg, University Medical Center Hamburg‐EppendorfHamburgGermany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/LuebeckHamburgGermany
| | - Sören Weidemann
- Department of PathologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Tanja Zeller
- Department of CardiologyUniversity Heart and Vascular Center Hamburg, University Medical Center Hamburg‐EppendorfHamburgGermany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/LuebeckHamburgGermany
- University Centre of Cardiovascular Science, UKE HamburgHamburgGermany
| | - Paulus Kirchhof
- Department of CardiologyUniversity Heart and Vascular Center Hamburg, University Medical Center Hamburg‐EppendorfHamburgGermany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/LuebeckHamburgGermany
| | - Daniel Reichart
- Department of Medicine IUniversity Hospital, LMU MunichMunichGermany
| | - Christina Magnussen
- Department of CardiologyUniversity Heart and Vascular Center Hamburg, University Medical Center Hamburg‐EppendorfHamburgGermany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/LuebeckHamburgGermany
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7
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Jain H, Reddy MMRK, Dey RC, Jain J, Shakhatreh Z, Manandhar S, Neupane P, Waleed MS, Yadav R, Sah BK, Mahawa R. Exploring Transthyretin Amyloid Cardiomyopathy: A Comprehensive Review of the Disease and Upcoming Treatments. Curr Probl Cardiol 2024; 49:102057. [PMID: 37640179 DOI: 10.1016/j.cpcardiol.2023.102057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 08/31/2023]
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is a mutation-based genetic disorder due to the accumulation of unstable transthyretin protein and presents with symptoms of congestive heart failure (CHF) and numerous extracardiac symptoms like carpal tunnel syndrome and neuropathy. Two subtypes of ATTR-CM are hereditary and wild-type, both of which have different risk factors, gender prevalence and major clinical symptoms. Timely usage of imaging modalities like echocardiography, cardiac magnetic imaging resonance, and cardiac scintigraphy has made it possible to suspect ATTR-CM in patients presenting with CHF. Management of ATTR-CM includes appropriate treatment for heart failure for symptomatic relief, prevention of arrhythmias and heart transplantation for nonresponders. With the recent approval of tafamidis in the successful management of ATTR-CM, numerous potential therapeutic points have been identified to stop or delay the progression of ATTR-CM. This article aims to provide a comprehensive review of ATTR-CM and insights into its novel therapeutics and upcoming treatments.
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Affiliation(s)
- Hritvik Jain
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India.
| | | | - Rohit Chandra Dey
- Department of Internal Medicine, Altai State Medical University, Barnaul, Russia
| | - Jyoti Jain
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Zaid Shakhatreh
- Department of Internal Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Sarbagya Manandhar
- Department of Internal Medicine, Nepal Medical College, Kathmandu, Nepal
| | - Purushottam Neupane
- Department of Internal Medicine, Punjab Medical College, Faisalabad, Pakistan
| | | | - Rukesh Yadav
- Department of Internal Medicine, Maharajgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj, Nepal
| | - Biki Kumar Sah
- Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Rukam Mahawa
- Department of Internal Medicine, Government Medical College, Amritsar, India
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8
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Golatkar V, Bhatt LK. Emerging therapeutic avenues in cardiac amyloidosis. Eur J Pharmacol 2023; 960:176142. [PMID: 37866746 DOI: 10.1016/j.ejphar.2023.176142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/15/2023] [Accepted: 10/19/2023] [Indexed: 10/24/2023]
Abstract
Cardiac Amyloidosis (CA) is a toxic infiltrative cardiomyopathy occurred by the deposition of the amyloid fibres in the extracellular matrix of the myocardium. This results in severe clinical complications such as increased left ventricular wall thickness and interventricular stiffness, a decrease in left ventricular stroke volume and cardiac output, diastolic dysfunction, arrhythmia, etc. In a prolonged period, this condition progresses into heart failure. The amyloid fibres affecting the heart include immunoglobulin light chain (AL - amyloidosis) and transthyretin protein (ATTR - amyloidosis) misfolded amyloid fibres. ATTRwt has the highest prevalence of 155 to 191 cases per million while ATTRv has an estimated prevalence of 5.2 cases per million. The pathological findings and therapeutic approaches developed recently have aided in the treatment regimen of cardiac amyloidosis patients. In recent years, understanding the pathophysiology of amyloid fibres formation and mechanistic pathways triggered in both types of cardiac amyloidosis has led to the development of new therapeutic approaches and agents. This review focuses on the current status of emerging therapeutic agents in clinical trials. Earlier, melphalan and bortezomib in combination with alkylating agents and immunomodulatory drugs were used as a standard therapy for AL amyloidosis. Tafamidis, approved recently by FDA is used as a standard for ATTR amyloidosis. However, the emerging therapeutic agents under development for the treatment of AL and ATTR cardiac amyloidosis have shown a potent and rapid effect with a safety profile.
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Affiliation(s)
- Vaishnavi Golatkar
- Department of Pharmacology, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, Vile Parle (W), Mumbai, India
| | - Lokesh Kumar Bhatt
- Department of Pharmacology, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, Vile Parle (W), Mumbai, India.
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Napolitano A, De Michieli L, Sinigiani G, Berno T, Cipriani A, Spiezia L. Thromboembolic and Bleeding Events in Transthyretin Amyloidosis and Coagulation System Abnormalities: A Review. J Clin Med 2023; 12:6640. [PMID: 37892778 PMCID: PMC10607836 DOI: 10.3390/jcm12206640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 10/29/2023] Open
Abstract
Transthyretin amyloidosis (ATTR) is a group of diseases caused by the deposition of insoluble fibrils derived from misfolded transthyretin, which compromises the structure and function of various organs, including the heart. Thromboembolic events and increased bleeding risk are among the most important complications of ATTR, though the underlying mechanisms are not yet fully understood. Transthyretin plays a complex role in the coagulation cascade, contributing to the activation and regulation of the coagulation and fibrinolytic systems. The prevalence of atrial fibrillation, cardiac mechanical dysfunction, and atrial myopathy in patients with ATTR may contribute to thrombosis, though such events may also occur in patients with a normal sinus rhythm and rarely in properly anticoagulated patients. Haemorrhagic events are modest and mainly linked to perivascular amyloid deposits with consequent capillary fragility and coagulation anomalies, such as labile international-normalised ratio during anticoagulant therapy. Therefore, it is paramount to carefully stratify the thrombotic and haemorrhagic risks, especially when initiating anticoagulant therapy. Our review aims to ascertain the prevalence of thromboembolic and haemorrhagic events in ATTR and identify potential risk factors and predictors and their impact on antithrombotic therapy.
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Affiliation(s)
- Angela Napolitano
- General Internal Medicine & Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, 35128 Padova, Italy;
| | - Laura De Michieli
- Department of Cardiothoracic and Vascular Sciences & Public Health, Padova University Hospital, 35128 Padova, Italy; (L.D.M.); (G.S.); (A.C.)
| | - Giulio Sinigiani
- Department of Cardiothoracic and Vascular Sciences & Public Health, Padova University Hospital, 35128 Padova, Italy; (L.D.M.); (G.S.); (A.C.)
| | - Tamara Berno
- Haematology Unit, Department of Medicine, Padova University Hospital, 35128 Padova, Italy;
| | - Alberto Cipriani
- Department of Cardiothoracic and Vascular Sciences & Public Health, Padova University Hospital, 35128 Padova, Italy; (L.D.M.); (G.S.); (A.C.)
| | - Luca Spiezia
- General Internal Medicine & Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, 35128 Padova, Italy;
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10
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Chatterjee S, Salimi A, Lee JY. Histidine tautomerism-mediated transthyretin amyloidogenesis: A molecular insight. Arch Biochem Biophys 2023; 742:109618. [PMID: 37172673 DOI: 10.1016/j.abb.2023.109618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 04/26/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023]
Abstract
Characterization of the conformational alterations involved in monomer misfolding is essential for elucidating the molecular basis of the initial stage of protein accumulation. Here, we report the first structural analyses of transthyretin (TTR) (26-57) fragments with two histidine tautomeric states (δ; Nδ1H and ε; Nε2H) using replica-exchange molecular dynamics (REMD) simulations. Explaining the organizational properties and misfolding procedure is challenging because the δ and ε configurations can occur in the free neutral state. REMD revealed that β-sheet generation is favored for the δδ (16.8%) and εδ (6.7%) tautomeric isomers, showing frequent main-chain contacts between the stable regions near the head (N-terminus) and central (middle) part compared to the εε (4.8%) and δε (2.8%) isomers. The presence of smaller and wider local energy minima may be related to the structural stability and toxicity of δδ/εδ and εε/δε. Histidines31 and 56 were the parts of regular (such as β-strand) and nonregular (such as coil) secondary structures within the highly toxic TTR isomer. For TTR amyloidosis, focusing on hazardous isomeric forms with high sheet contents may be a potent treatment strategy. Overall, our findings support the tautomerism concept and aid in our comprehension of the basic tautomeric actions of neutral histidine throughout the misfolding process.
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Affiliation(s)
- Sompriya Chatterjee
- Department of Chemistry, Sungkyunkwan University, Suwon, 440-746, South Korea
| | - Abbas Salimi
- Department of Chemistry, Sungkyunkwan University, Suwon, 440-746, South Korea
| | - Jin Yong Lee
- Department of Chemistry, Sungkyunkwan University, Suwon, 440-746, South Korea.
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11
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Knoll K, Fuchs P, Trenkwalder T. Kardiale Amyloidose. CARDIOVASC 2023. [PMCID: PMC10063327 DOI: 10.1007/s15027-023-2968-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
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12
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Laptseva N, Rossi VA, Sudano I, Schwotzer R, Ruschitzka F, Flammer AJ, Duru F. Arrhythmic Manifestations of Cardiac Amyloidosis: Challenges in Risk Stratification and Clinical Management. J Clin Med 2023; 12:jcm12072581. [PMID: 37048664 PMCID: PMC10095126 DOI: 10.3390/jcm12072581] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Amylodiosis is a systemic disease characterized by extracellular deposits of insoluble amyloid in various tissues and organs. Cardiac amyloidosis is a frequent feature of the disease, causing a progressive, restrictive type of cardiomyopathy, and is associated with adverse clinical outcomes and increased mortality. The typical clinical presentation in patients with cardiac amyloidosis is heart failure (HF) with preserved ejection fraction. Most patients present with typical symptoms and signs of HF, such as exertional dyspnea, pretibial edema, pleural effusions and angina pectoris due to microcirculatory dysfunction. However, patients may also frequently encounter various arrhythmias, such as atrioventricular nodal block, atrial fibrillation and ventricular tachyarrhythmias. The management of arrhythmias in cardiac amyloidosis patients with drugs and devices is often a clinical challenge. Moreover, predictors of life-threatening arrhythmic events are not well defined. This review intends to give a deepened insight into the arrhythmic features of cardiac amyloidosis by discussing the pathogenesis of these arrhythmias, addressing the challenges in risk stratification and strategies for management in these patients.
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Jhawar N, Moreno JCL, Chirila R. A review of transthyretin cardiac amyloidosis. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2023; 61:28-34. [PMID: 36278951 DOI: 10.2478/rjim-2022-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Indexed: 11/07/2022]
Abstract
Transthyretin cardiac amyloidosis is a progressive disease known to cause heart failure, conduction anomalies, and arrythmias. Due to poor outcomes and mortality from severe cardiomyopathy, prevalence and incident rates are often underreported. As global longevity is increasing and rates of amyloidosis are also increasing, there is a need to improve diagnostic and therapeutic interventions. Previously, symptom management and transplantation were the mainstay of treatment for heart failure symptoms, but studies using RNAi and siRNA technologies have shifted the paradigm of therapeutic strategy in amyloid cardiomyopathy management. Additionally, early detection and clinical monitoring with numerous imaging and non-imaging techniques are being increasingly investigated. Here, we review the epidemiology, pathophysiology, diagnosis, and management of transthyretin amyloid cardiomyopathy.
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Affiliation(s)
- Nikita Jhawar
- Department of Internal Medicine, Mayo Clinic, 4500 San Pablo Road S Jacksonville, FL 32224
| | - Juan Carlos Leoni Moreno
- Department of Advanced Heart Failure and Transplant, Mayo Clinic 4500 San Pablo Road S Jacksonville, FL 32224
| | - Razvan Chirila
- Department of Internal Medicine, Mayo Clinic, 4500 San Pablo Road S Jacksonville, FL 32224
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14
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Al Musaimi O, Al Shaer D, Albericio F, de la Torre BG. 2022 FDA TIDES (Peptides and Oligonucleotides) Harvest. Pharmaceuticals (Basel) 2023; 16:ph16030336. [PMID: 36986436 PMCID: PMC10056021 DOI: 10.3390/ph16030336] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/13/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
A total of 37 new drug entities were approved in 2022; although that year registered the lowest number of drug approvals since 2016, the TIDES class consolidated its presence with a total of five authorizations (four peptides and one oligonucleotide). Interestingly, 23 out of 37 drugs were first-in-class and thus received fast-track designation by the FDA in categories such as breakthrough therapy, priority review voucher, orphan drug, accelerated approval, and so on. Here, we analyze the TIDES approved in 2022 on the basis of their chemical structure, medical target, mode of action, administration route, and common adverse effects.
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Affiliation(s)
- Othman Al Musaimi
- Department of Chemical Engineering, Imperial College London, London SW7 2AZ, UK
- Correspondence: (O.A.M.); (B.G.d.l.T.); Tel.: +44-7398-561-752 (O.A.M.); +27-614047528 (B.G.d.l.T.)
| | - Danah Al Shaer
- Department of Medicinal Chemistry, Evotec (UK) Ltd., Abingdon OX14 4R, UK
| | - Fernando Albericio
- School of Chemistry and Physics, University of KwaZulu-Natal, Durban 4001, South Africa
- CIBER-BBN, Networking Centre on Bioengineering, Biomaterials and Nanomedicine, Department of Organic Chemistry, University of Barcelona, 08028 Barcelona, Spain
| | - Beatriz G. de la Torre
- KRISP, College of Health Sciences, University of KwaZulu-Natal, Durban 4001, South Africa
- Correspondence: (O.A.M.); (B.G.d.l.T.); Tel.: +44-7398-561-752 (O.A.M.); +27-614047528 (B.G.d.l.T.)
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Abstract
Vutrisiran (AMVUTTRA™) is a subcutaneously administered transthyretin-directed small interfering ribonucleic acid (siRNA) therapeutic (also called RNA interference, or RNAi therapeutic) being developed by Alnylam Pharmaceuticals, Inc. for the treatment of amyloid transthyretin-mediated (ATTR) amyloidosis, including hereditary ATTR (hATTR) amyloidosis and wild-type ATTR (wtATTR) amyloidosis. Vutrisiran was approved in June 2022 in the USA for the treatment of the polyneuropathy of hATTR amyloidosis in adults and received a positive opinion in the EU in July 2022 for the treatment of hATTR amyloidosis in adult patients with stage 1 or stage 2 polyneuropathy. Vutrisiran is also under regulatory review for the treatment of the polyneuropathy of hATTR amyloidosis in adults in Japan and Brazil. This article summarizes the milestones in the development of vutrisiran leading to this first approval in hATTR amyloidosis.
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Affiliation(s)
- Susan J Keam
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand.
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Martínez-Martínez E, Fernández-Irigoyen J, Santamaría E, Nieto ML, Bravo-San Pedro JM, Cachofeiro V. Mitochondrial Oxidative Stress Induces Cardiac Fibrosis in Obese Rats through Modulation of Transthyretin. Int J Mol Sci 2022; 23:ijms23158080. [PMID: 35897655 PMCID: PMC9330867 DOI: 10.3390/ijms23158080] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/20/2022] [Accepted: 07/20/2022] [Indexed: 02/01/2023] Open
Abstract
A proteomic approach was used to characterize potential mediators involved in the improvement in cardiac fibrosis observed with the administration of the mitochondrial antioxidant MitoQ in obese rats. Male Wistar rats were fed a standard diet (3.5% fat; CT) or a high-fat diet (35% fat; HFD) and treated with vehicle or MitoQ (200 μM) in drinking water for 7 weeks. Obesity modulated the expression of 33 proteins as compared with controls of the more than 1000 proteins identified. These include proteins related to endoplasmic reticulum (ER) stress and oxidative stress. Proteomic analyses revealed that HFD animals presented with an increase in cardiac transthyretin (TTR) protein levels, an effect that was prevented by MitoQ treatment in obese animals. This was confirmed by plasma levels, which were associated with those of cardiac levels of both binding immunoglobulin protein (BiP), a marker of ER stress, and fibrosis. TTR stimulated collagen I production and BiP in cardiac fibroblasts. This upregulation was prevented by the presence of MitoQ. In summary, the results suggest a role of TTR in cardiac fibrosis development associated with obesity and the beneficial effects of treatment with mitochondrial antioxidants.
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Affiliation(s)
- Ernesto Martínez-Martínez
- Departamento de Fisiología, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain;
- Ciber de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28222 Madrid, Spain;
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28007 Madrid, Spain
- Correspondence: (E.M.-M.); (V.C.); Tel.: +34-913-941-483 (E.M.-M.); +34-913-941-489 (V.C.)
| | - Joaquín Fernández-Irigoyen
- Proteomics Platform, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, 31008 Pamplona, Spain; (J.F.-I.); (E.S.)
| | - Enrique Santamaría
- Proteomics Platform, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, 31008 Pamplona, Spain; (J.F.-I.); (E.S.)
| | - María Luisa Nieto
- Ciber de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28222 Madrid, Spain;
- Instituto de Biología y Genética Molecular, CSIC-Universidad de Valladolid, 47002 Valladolid, Spain
| | | | - Victoria Cachofeiro
- Departamento de Fisiología, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain;
- Ciber de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28222 Madrid, Spain;
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28007 Madrid, Spain
- Correspondence: (E.M.-M.); (V.C.); Tel.: +34-913-941-483 (E.M.-M.); +34-913-941-489 (V.C.)
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