Role and molecular mechanisms of SGLT2 inhibitors in pathological cardiac remodeling (Review)

Peripartum dapagliflozin improves late-life maternal cardiovascular outcomes in a murine model of superimposed preeclampsia

BACKGROUND

Hypertensive disorders of pregnancy are important risk factors for later-life cardiovascular diseases. SGLT2 (sodium-glucose cotransporter-2) inhibition improves outcomes in heart failure, a later-life risk that disproportionately affects those with preeclampsia superimposed on chronic hypertension. SGLT2 inhibition during pregnancy and the postpartum period has not been effectively modeled or tested in superimposed preeclampsia as a potential cardiovascular risk-reducing intervention.

OBJECTIVE

This study aimed to (1) confirm the phenotype of superimposed preeclampsia in the BPH/2J mouse model, (2) test the short- and long-term obstetrical and cardiovascular effects of administering an SGLT2 inhibitor (dapagliflozin) in pregnancy and the immediate postpartum period in this model, and (3) identify molecular effects of SGLT2 inhibition in cardiovascular tissues during and after a treated pregnancy.

STUDY DESIGN

We established the BPH/2J model of superimposed preeclampsia and then randomly assigned pregnant BPH/2J mice with implanted telemetry devices to dapagliflozin-enriched chow or control chow starting early in gestation through 21 days after delivery. Maternal cardiovascular and obstetrical outcomes including circulating plasma protein markers, urine studies, obstetrical ultrasounds, and tissue histopathology were compared between the groups. Hearts and aortae were analyzed using serial echocardiography and spatial transcriptomics in late gestation or at 6 months postpartum.

RESULTS

BPH/2J mice had baseline chronic hypertension that worsened in pregnancy with the development of proteinuria and elevated plasma sFlt-1 levels, consistent with superimposed preeclampsia. Mid-gestation systolic blood pressures were higher in the untreated group than the dapagliflozin-treated group (+2.87 mm Hg; P<.001). There were no differences in the number of pups or estimated fetal pup weights between the groups, whereas amniotic fluid volume, placental size, and markers of placental perfusion were improved in the dapagliflozin-treated group. The untreated group had higher aortic peak velocities in late pregnancy compared with the dapagliflozin-treated group (748.1 vs 561.9 mm/s; P=.004×10-3). One maternal death occurred in the untreated group, with no events in the dapagliflozin-treated group. In late life, the untreated group had significant loss of left ventricular function relative to their prepregnancy baseline, whereas dapagliflozin-treated mice had relatively preserved left ventricular function (-20.0% vs -7.6% change; P=.004×10-3; 49.0%±6.34% untreated-baseline to 30.5%±6.78% untreated-aged; 44.9%±8.63% treated-baseline to 36.5%±6.39% treated-aged). Tissue transcriptomic analyses and Masson's trichrome staining demonstrated attenuation of cardiac fibrosis and extracellular remodeling processes with SGLT2 inhibition.

CONCLUSION

In a murine model of superimposed preeclampsia, dapagliflozin treatment during pregnancy and the puerperium improved physiological cardiovascular parameters during gestation and cardiac function later in life. This may be related to observed molecular effects of SGLT2 inhibition treatment, particularly its antifibrotic and metabolic actions associated with reduced markers of fibrotic pathologic remodeling in treated BPH/2Js during and after pregnancy.

Development and validation of an integrated prognostic model for all-cause mortality in heart failure: a comprehensive analysis combining clinical, electrocardiographic, and echocardiographic parameters

BACKGROUND

Accurate risk prediction in heart failure remains challenging due to its complex pathophysiology. We aimed to develop and validate a comprehensive prognostic model integrating demographic, electrocardiographic, echocardiographic, and biochemical parameters.

METHODS

We conducted a retrospective cohort study of 445 heart failure patients. The cohort was randomly divided into training (n = 312) and validation (n = 133) sets. Feature selection was performed using LASSO regression followed by backward stepwise Cox regression. A nomogram was constructed based on independent predictors. Model performance was assessed through discrimination, calibration, and decision curve analyses. Random survival forest analysis was conducted to validate variable importance.

RESULTS

During a median follow-up of 4.14 years, 142 deaths (31.91%) occurred. Our model development followed a systematic approach: initial feature selection using LASSO regression identified 15 potential predictors, which were further refined to nine independent predictors through backward stepwise Cox regression. The final predictors included age, NYHA class, left ventricular systolic dysfunction, atrial septal defect, aortic valve annulus calcification, tricuspid regurgitation severity, QRS duration, T wave offset, and NT-proBNP. The integrated model demonstrated good discrimination for 2-, 3-, and 5-year mortality prediction in both training (AUCs: 0.726, 0.755, 0.809) and validation cohorts (AUCs: 0.686, 0.678, 0.706). Calibration plots and decision curve analyses confirmed the model's reliability and clinical utility across different time horizons. A nomogram was constructed for individualized risk prediction. Kaplan-Meier analyses of individual predictors revealed significant stratification of survival outcomes, while restricted cubic spline analyses demonstrated non-linear relationships between continuous variables and mortality risk. Random survival forest analysis identified the top five predictors (age, NT-proBNP, QRS duration, tricuspid regurgitation severity, NYHA), which were compared with our nine-variable model, confirming the superior performance of the integrated model across all time points.

CONCLUSIONS

Our integrated prognostic model showed robust performance in predicting all-cause mortality in heart failure patients. The model's ability to provide individualized risk estimates through a nomogram may facilitate clinical decision-making and patient stratification.

CLINICAL TRIAL NUMBER

Not applicable.

Implications of Heart Failure Treatment on Atrial Fibrillation Onset: A Retrospective Study

Background and Objectives: Atrial fibrillation (AF) is one of the most common supraventricular arrhythmias in the adult population worldwide and it is frequently associated with heart failure (HF). The coexistence of these conditions increases morbidity, mortality and reduces quality of life in these patients. Therefore, it is important to delay the onset of AF in HF patients in order to avoid complications. The study aims to assess whether HF treatment influences AF onset. Materials and Methods: This retrospective observational study included 260 patients, 144 patients with heart failure treated with sodium-glucose cotransporter 2 inhibitors (SGLT2i) and 116 patients with heart failure without SGLT2i treatment (control group) hospitalized at least twice in the Cardiology Department of the "Pius Brinzeu" Emergency County Hospital between 2022 and 2024. Results: Treatment with SGLT2i was associated with a lower prevalence of atrial fibrillation in patients with heart failure. Conclusions: The study highlights the cardiovascular benefits of SGLT2 inhibitors and suggests a potential effect on the onset of AF in heart failure patients.

Anti-Inflammatory Effects of SGLT2 Inhibitors: Focus on Macrophages

A growing body of evidence indicates that nonglycemic effects of sodium-glucose cotransporter 2 (SGLT2) inhibitors play an important role in the protective effects of these drugs in diabetes, chronic kidney disease, and heart failure. In recent years, the anti-inflammatory potential of SGLT2 inhibitors has been actively studied. This review summarizes results of clinical and experimental studies on the anti-inflammatory activity of SGLT2 inhibitors, with a special focus on their effects on macrophages, key drivers of metabolic inflammation. In patients with type 2 diabetes, therapy with SGLT2 inhibitors reduces levels of inflammatory mediators. In diabetic and non-diabetic animal models, SGLT2 inhibitors control low-grade inflammation by suppressing inflammatory activation of tissue macrophages, recruitment of monocytes from the bloodstream, and macrophage polarization towards the M1 phenotype. The molecular mechanisms of the effects of SGLT2 inhibitors on macrophages include an attenuation of inflammasome activity and inhibition of the TLR4/NF-κB pathway, as well as modulation of other signaling pathways (AMPK, PI3K/Akt, ERK 1/2-MAPK, and JAKs/STAT). The review discusses the state-of-the-art concepts and prospects of further investigations that are needed to obtain a deeper insight into the mechanisms underlying the effects of SGLT2 inhibitors on the molecular, cellular, and physiological levels.

The protective effects of liraglutide in reducing lipid droplets accumulation and myocardial fibrosis in diabetic cardiomyopathy

BACKGROUND

Diabetes is a primary contributor to diabetic cardiomyopathy (DbCM), which is marked by metabolic imbalances such as elevated blood glucose and lipid levels, leading to significant structural and functional alterations in the myocardium. Elevated free fatty acids (FFAs) and hyperglycemia play critical roles in DbCM development, with FFAs inducing insulin resistance in cardiomyocytes and promoting lipid accumulation, resulting in oxidative stress and fibrosis. Current research suggests that glucagon-like peptide-1 (GLP-1) receptor agonists may effectively mitigate DbCM, although an effective treatment for this condition remains elusive, and the precise mechanisms of this protective effect are not fully understood.

METHODS

In this study, we aimed to replicate diabetic glucolipotoxic conditions by treating differentiated H9c2 cells with high glucose and free fatty acids. Additionally, a diabetic cardiomyopathy model was induced in mice through high-fat diets. Both in vitro and in vivo models were used to investigate the protective effects of liraglutide on cardiomyocytes and elucidate its underlying molecular mechanisms.

RESULTS

Our findings indicate that liraglutide significantly reduces lipid droplet (LD) formation and myocardial fibrosis, as evidenced by decreased expression of fibrosis markers, including TGF-β1 and collagen types I and III. Liraglutide also enhanced AMP-activated protein kinase (AMPK) activation, which improved mitochondrial function, increased antioxidant gene expression, enhanced insulin signaling, and reduced oxidative stress.

CONCLUSIONS

These results demonstrate the potential therapeutic role of liraglutide in managing diabetes-related cardiac complications, offering a comprehensive approach to improving cardiac outcomes in patients with diabetes.

SGLT2 Inhibitors and How They Work Beyond the Glucosuric Effect. State of the Art

Type 2 diabetes mellitus (T2DM) is associated with a heightened risk of cardiovascular and renal complications. While glycemic control remains essential, newer therapeutic options, such as SGLT2 inhibitors, offer additional benefits beyond glucose reduction. This review delves into the mechanisms underlying the cardio-renal protective effects of SGLT2 inhibitors. By inducing relative hypoglycemia, these agents promote ketogenesis, optimize myocardial energy metabolism, and reduce lipotoxicity. Additionally, SGLT2 inhibitors exert renoprotective actions by enhancing renal perfusion, attenuating inflammation, and improving iron metabolism. These pleiotropic effects, including modulation of blood pressure, reduction of uric acid, and improved endothelial function, collectively contribute to the cardiovascular and renal benefits observed with SGLT2 inhibitor therapy. This review will provide clinicians with essential knowledge, understanding, and a clear recollection of this pharmacological group's mechanism of action.

Heart Failure with Preserved Ejection Fraction and Cardiac Amyloidosis in the Aging Heart

Heart Failure with Preserved Ejection Fraction (HFpEF) is one of the most frequent causes of heart failure in the world's population (about 19-55%), and is commonly associated with a high rate of hospitalization (almost 70-80%) and with increased mortality (40-50% in a 5-year timeframe). The elderly are more often affected, with higher rates of hospitalizations than young people, and currently almost 70% of the population aged 65 years old has HFpEF. An increase in cardiomyocyte stiffness, thus resulting in diastolic dysfunction, increased filling pressures and heart failure with preserved ejection fraction are characteristics features of the disease. In addition, among the various causes of HFpEF, cardiac amyloidosis (CA) can provoke diastolic dysfunction and increased wall stiffness directly from intercellular deposition of insoluble proteic substances and their toxic activity. Totally, almost 30 different proteins are able to form deposits, but the most frequently involved are transthyretin and misfolded monoclonal immunoglobulin light chains, which bring to two clinical conditions called transthyretin amyloidosis (ATTR) and light-chain amyloidosis (AL). Although there has been increasing attention on ATTR-CA in recent years, the actual prevalence remains underestimated, especially in people of advanced age, as well as its real impact as a cause of HFpEF, and only data derived from autoptic exams are currently available. Moreover, CA itself often mimics HFpEF, and some conflicting data on the use of predictive scores are described in the literature. The close relationship between HFpEF and CA, especially in older population and the main pathophysiological mechanisms which bond these two conditions are described in this focused review. The need to screen red flags for ATTR-CA in elderly patients with HFpEF is urgently advised, because a prompt recognition of the disease can optimize the approach to the disease with an early therapeutic, life-saving choice.

The role of GZMA as a target of cysteine and biomarker in Alzheimer's disease, pelvic organ prolapse, and tumor progression

Objective: This study aims to investigate how changes in peripheral blood metabolites in Alzheimer's Disease (AD) patients affect the development of Pelvic Organ Prolapse (POP) using a multi-omics approach. We specifically explore the interactions of signaling pathways, gene expression, and protein-metabolite interactions, with a focus on GZMA and cysteine in age-related diseases. Methods: This study utilized multi-omics analysis, including metabolomics and transcriptomics, to evaluate the perturbations in peripheral blood metabolites and their effect on POP in AD patients. Additionally, a comprehensive pan-cancer and immune infiltration analysis was performed on the core targets of AD combined with POP, exploring their potential roles in tumor progression and elucidating their pharmacological relevance to solid tumors. Results: We identified 47 differential metabolites linked to 9 significant signaling pathways, such as unsaturated fatty acid biosynthesis and amino acid metabolism. A thorough gene expression analysis revealed numerous differentially expressed genes (DEGs), with Gene Set Enrichment Analysis (GSEA) showing significant changes in gene profiles of AD and POP. Network topology analysis highlighted central nodes in the AD-POP co-expressed genes network. Functional analyses indicated involvement in critical biological processes and pathways. Molecular docking studies showed strong interactions between cysteine and proteins PTGS2 and GZMA, and molecular dynamics simulations confirmed the stability of these complexes. In vitro validation demonstrated that cysteine reduced ROS levels and protected cell viability. GZMA was widely expressed in various cancers, associated with immune cells, and correlated with patient survival prognosis. Conclusion: Multi-omics analysis revealed the role of peripheral blood metabolites in the molecular dynamics of AD and their interactions with POP. This study identified potential biomarkers and therapeutic targets, emphasizing the effectiveness of integrative approaches in treating AD and POP concurrently. The findings highlight the need for in-depth research on novel targets and biomarkers to advance therapeutic strategies.