Obesity and Cardioprotection

Cardioprotective Strategies After Ischemia-Reperfusion Injury

Acute myocardial infarction (AMI) is associated with high morbidity and mortality worldwide. Although early reperfusion is the most effective strategy to salvage ischemic myocardium, reperfusion injury can develop with the restoration of blood flow. Therefore, it is important to identify protection mechanisms and strategies for the heart after myocardial infarction. Recent studies have shown that multiple intracellular molecules and signaling pathways are involved in cardioprotection. Meanwhile, device-based cardioprotective modalities such as cardiac left ventricular unloading, hypothermia, coronary sinus intervention, supersaturated oxygen (SSO2), and remote ischemic conditioning (RIC) have become important areas of research. Herein, we review the molecular mechanisms of cardioprotection and cardioprotective modalities after ischemia-reperfusion injury (IRI) to identify potential approaches to reduce mortality and improve prognosis in patients with AMI.

Discovery of a novel 1,3,4-oxadiazol-2-one-based NLRP3 inhibitor as a pharmacological agent to mitigate cardiac and metabolic complications in an experimental model of diet-induced metaflammation

Inspired by the recent advancements in understanding the binding mode of sulfonylurea-based NLRP3 inhibitors to the NLRP3 sensor protein, we developed new NLRP3 inhibitors by replacing the central sulfonylurea moiety with different heterocycles. Computational studies evidenced that some of the designed compounds were able to maintain important interaction within the NACHT domain of the target protein similarly to the most active sulfonylurea-based NLRP3 inhibitors. Among the studied compounds, the 1,3,4-oxadiazol-2-one derivative 5 (INF200) showed the most promising results being able to prevent NLRP3-dependent pyroptosis triggered by LPS/ATP and LPS/MSU by 66.3 ± 6.6% and 61.6 ± 11.5% and to reduce IL-1β release (35.5 ± 8.8% μM) at 10 μM in human macrophages. The selected compound INF200 (20 mg/kg/day) was then tested in an in vivo rat model of high-fat diet (HFD)-induced metaflammation to evaluate its beneficial cardiometabolic effects. INF200 significantly counteracted HFD-dependent "anthropometric" changes, improved glucose and lipid profiles, and attenuated systemic inflammation and biomarkers of cardiac dysfunction (particularly BNP). Hemodynamic evaluation on Langendorff model indicate that INF200 limited myocardial damage-dependent ischemia/reperfusion injury (IRI) by improving post-ischemic systolic recovery and attenuating cardiac contracture, infarct size, and LDH release, thus reversing the exacerbation of obesity-associated damage. Mechanistically, in post-ischemic hearts, IFN200 reduced IRI-dependent NLRP3 activation, inflammation, and oxidative stress. These results highlight the potential of the novel NLRP3 inhibitor, INF200, and its ability to reverse the unfavorable cardio-metabolic dysfunction associated with obesity.

Advanced endoscopic gastrointestinal techniques for the bariatric patient: implications for the anesthesia provider

PURPOSE OF REVIEW

The incidence of obesity and the use of endoscopy have risen concurrently throughout the 21st century. Bariatric patients may present to the endoscopy suite for primary treatments as well as preoperatively and postoperatively from bariatric surgery. However, over the past 10 years, endoscopic bariatric and metabolic therapies (EBMTs) have emerged as viable alternatives to more invasive surgical approaches for weight loss.

RECENT FINDINGS

The United States Food and Drug Administration (FDA) has approved several different gastric EBMTs including aspiration therapy, intragastric balloons, and endoscopic suturing. Other small intestine EBMTs including duodenal mucosal resurfacing, endoluminal magnetic partial jejunal diversion, and Duodenal-Jejunal Bypass Liner are not yet FDA approved, but are actively being investigated.

SUMMARY

Obesity causes anatomic and physiologic changes to every aspect of the human body. All EBMTs have specific nuances with important implications for the anesthesiologist. By considering both patient and procedural factors, the anesthesiologist will be able to perform a safe and effective anesthetic.

Long-Term High-Fat Diet Inhibits the Recovery of Myocardial Mitochondrial Function After Chronic Hypoxia Reoxygenation in Rats

Yan, Jun, Kang Song, Sisi Zhou, and Ri-Li Ge. Long-term high-fat diet inhibits the recovery of myocardial mitochondrial function after chronic hypoxia reoxygenation in rats. High Alt Med Biol. 16:000-000, 2021. Aims: A high-fat diet (HFD) is associated with cardiovascular diseases and mitochondrial dysfunction. Obesity incidence is low at high altitudes, but the impact of HFD, which is closely associated with obesity at high altitudes, and the effects of reoxygenation on the heart are unclear. In this study, we investigated the effects of long-term HFD consumption on mitochondrial function in the myocardium after chronic hypoxia reoxygenation. Main Methods: Sprague-Dawley rats were randomized into the following six groups: normoxia groups, including a control group and HFD group; chronic hypoxia groups, including a normal chow diet (CH-CD) group and an HFD (CH-HFD) group; and hypoxic-reoxygenated (HR) groups, including a hypoxia-reoxygenation normal chow diet (HR-CD) group and a hypoxia-reoxygenation HFD (HR-HFD) group. All rats were euthanized in this study. Results: We found that chronic hypoxia aggravated myocardial mitochondrial dysfunction. The Flameng score (in which the higher the score, the more severe the mitochondrial damage) was used to assess the extent of mitochondrial structural damage. Compared with the control group and HFD group, the Flameng scores of the CH-CD and CH-HFD groups were significantly increased, respectively [1.260 ± 0.063 vs. 0.68 ± 0.05 (p < 0.05); 2.03 ± 0.07 vs. 1.48 ± 0.05 (p < 0.05)]. Moreover, progressive reoxygenation facilitated the recovery of myocardial mitochondrial function; this process was inhibited by long-term HFD. After reoxygenation, the Flameng scores in the HR-CD group became comparable to those in the CH-CD group [0.86 ± 0.05 vs. 1.26 ± 0.06 (p < 0.05)]. However, no significant changes were observed in the Flameng score between the HR-HFD and CH-HFD groups. Significance: Long-term HFD consumption inhibits myocardial mitochondrial function after reoxygenation. This finding may be helpful for the prevention and control of risk factors related to cardiovascular diseases in plateau residents.

The obesity paradox and diabetes

BACKGROUND

Obesity has been proven to be a risk factor for type 2 diabetes mellitus (T2DM) through numerous pathogenetic mechanisms. Unexpectedly, some studies suggest that subjects with overweight/obesity and T2DM have better clinical outcome than their normal weight peers. This finding is described as "obesity paradox" and calls into question the importance of weight loss in this specific population.

OBJECTIVE

This article is a narrative overview on the obesity and type 2 diabetes mellitus, particularly regarding the obesity paradox in T2DM patients.

METHODS

We used as sources MEDLINE/PubMed, CINAHL, EMBASE, and Cochrane Library, from inception to March 2020; we chose 30 relevant papers regarding the association of obesity with clinical outcome and mortality of patients affected by T2DM.

RESULTS

Many studies report that in patients with T2DM, overweight and obesity are associated with a better prognosis than underweight or normal weight, suggesting the presence of an obesity paradox. However, these studies have numerous limitations due to their mainly retrospective nature and to numerous confounding factors, such as associated pathologies, antidiabetic treatments, smoking habit, lack of data about distribution of body fat or weight history.

CONCLUSION

Literature data regarding the phenomenon of obesity paradox in T2DM patients are controversial due to the several limitations of the studies; therefore in the management of patients with overweight/obesity and T2DM is recommended referring to the established guidelines, which indicate diet and physical activity as the cornerstone of the treatment.

LEVEL OF EVIDENCE

Level V: narrative review.

WY14643 improves left ventricular myocardial mitochondrial and systolic functions in obese rats under chronic persistent hypoxia via the PPARα pathway

AIMS

Peroxisome proliferator-activated receptor (PPAR) α, a key regulator of lipid metabolism, plays a role in maintaining the homeostasis of myocardial energy metabolism. Both hypoxia and obesity inhibit the expression of PPARα in the myocardium. In this study, we verified the inhibitory effects of hypoxia and obesity on PPARα and examined whether WY14643 (4-chloro-6-(2,3-xylidino)-2-pyrimidinylthioacetic acid), an agonist of PPARα, ameliorates myocardial mitochondrial dysfunction and protects cardiac function in obese rats under chronic persistent hypoxia.

MAIN METHODS

Sprague-Dawley rats were randomly divided into six groups: a control group (normal chow diet, normal oxygen), a high-fat diet (HFD) group (normal oxygen), a chronic persistent hypoxia normal chow diet group, a chronic persistent hypoxia HFD group, a chronic persistent hypoxia HFD group with WY14643 treatment, and a chronic persistent hypoxia HFD group with vehicle treatment.

KEY FINDINGS

Hypoxia and obesity increased myocardial lipid accumulation, mitochondrial dysfunction, and left ventricular systolic dysfunction. Myocardial lipid metabolism-related genes, including those encoding PPARα, PPARγ coactivator 1α (PGC1α), and carnitine palmitoyl transferase 1α (CPT1α), were downregulated, while acetyl-CoA carboxylase 2 (ACC2) was upregulated under a combination of hypoxia and obesity. WY14643 upregulated PPARα, PGC1α, and CPT1α, and downregulated ACC2. WY14643 alleviated hypoxia- and obesity-induced myocardial lipid accumulation and improved mitochondrial and left ventricular systolic functions.

SIGNIFICANCE

WY14643 improved myocardial mitochondrial and left ventricular systolic functions in obese rats under chronic persistent hypoxia. Thus, WY14643 possibly exerts its effects by regulating the PPARα pathway and shows potential as a therapeutic target for cardiovascular diseases associated with obesity and hypoxia.

The Role of Oxytocin in Cardiovascular Protection

The beneficial effects of oxytocin on infarct size and functional recovery of the ischemic reperfused heart are well documented. The mechanisms for this cardioprotection are not well defined. Evidence indicates that oxytocin treatment improves cardiac work, reduces apoptosis and inflammation, and increases scar vascularization. Oxytocin-mediated cytoprotection involves the production of cGMP stimulated by local release of atrial natriuretic peptide and synthesis of nitric oxide. Treatment with oxytocin reduces the expression of proinflammatory cytokines and reduces immune cell infiltration. Oxytocin also stimulates differentiation stem cells to cardiomyocyte lineages as well as generation of endothelial and smooth muscle cells, promoting angiogenesis. The beneficial actions of oxytocin may include the increase in glucose uptake by cardiomyocytes, reduction in cardiomyocyte hypertrophy, decrease in oxidative stress, and mitochondrial protection of several cell types. In cardiac and cellular models of ischemia and reperfusion, acute administration of oxytocin at the onset of reperfusion enhances cardiomyocyte viability and function by activating Pi3K and Akt phosphorylation and downstream cellular signaling. Reperfusion injury salvage kinase and signal transducer and activator of transcription proteins cardioprotective pathways are involved. Oxytocin is cardioprotective by reducing the inflammatory response and improving cardiovascular and metabolic function. Because of its pleiotropic nature, this peptide demonstrates a clear potential for the treatment of cardiovascular pathologies. In this review, we discuss the possible cellular mechanisms of action of oxytocin involved in cardioprotection.

Ticagrelor Conditioning Effects Are Not Additive to Cardioprotection Induced by Direct NLRP3 Inflammasome Inhibition: Role of RISK, NLRP3, and Redox Cascades

Inhibition of either P2Y12 receptor or the nucleotide-binding oligomerization domain- (NOD-) like receptor pyrin domain containing 3 (NLRP3) inflammasome provides cardioprotective effects. Here, we investigate whether direct NLRP3 inflammasome inhibition exerts additive effects on myocardial protection induced by the P2Y12 receptor antagonist Ticagrelor. Ticagrelor (150 mg/kg) was orally administered to rats for three consecutive days. Then, isolated hearts underwent an ischemia/reperfusion (30 min ischemia/60 min reperfusion; IR) protocol. The selective NLRP3 inflammasome inhibitor INF (50 μM) was infused before the IR protocol to the hearts from untreated animals or pretreated with Ticagrelor. In parallel experiments, the hearts isolated from untreated animals were perfused with Ticagrelor (3.70 μM) before ischemia and subjected to IR. The hearts of animals pretreated with Ticagrelor showed a significantly reduced infarct size (IS, 49 ± 3% of area at risk, AAR) when compared to control IR group (69 ± 2% of AAR). Similarly, ex vivo administration of INF before the IR injury resulted in significant IS reduction (38 ± 3% of AAR). Myocardial IR induced the NLRP3 inflammasome complex formation, which was attenuated by either INF pretreatment ex vivo, or by repeated oral treatment with Ticagrelor. The beneficial effects induced by either treatment were associated with the protective Reperfusion Injury Salvage Kinase (RISK) pathway activation and redox defence upregulation. In contrast, no protective effects nor NLRP3/RISK modulation were recorded when Ticagrelor was administered before ischemia in isolated heart, indicating that Ticagrelor direct target is not in the myocardium. Our results confirm that Ticagrelor conditioning effects are likely mediated through platelets, but are not additives to the ones achieved by directly inhibiting NLRP3.

Diabetic Cardiomyopathy and Ischemic Heart Disease: Prevention and Therapy by Exercise and Conditioning

Metabolic syndrome, diabetes, and ischemic heart disease are among the leading causes of death and disability in Western countries. Diabetic cardiomyopathy is responsible for the most severe signs and symptoms. An important strategy for reducing the incidence of cardiovascular disease is regular exercise. Remote ischemic conditioning has some similarity with exercise and can be induced by short periods of ischemia and reperfusion of a limb, and it can be performed in people who cannot exercise. There is abundant evidence that exercise is beneficial in diabetes and ischemic heart disease, but there is a need to elucidate the specific cardiovascular effects of emerging and unconventional forms of exercise in people with diabetes. In addition, remote ischemic conditioning may be considered among the options to induce beneficial effects in these patients. The characteristics and interactions of diabetes and ischemic heart disease, and the known effects of exercise and remote ischemic conditioning in the presence of metabolic syndrome and diabetes, are analyzed in this brief review.