Pirfenidone as a novel cardiac protective treatment

Myocardial fibrosis is a common feature of several heart diseases. The progressive deposition of extracellular matrix due to a persistent injury to cardiomyocytes may trigger a vicious cycle that leads to persistent structural and functional alterations of the myocardium. Some drugs (like renin–angiotensin–aldosterone system inhibitors) have been shown to reduce extracellular matrix deposition, but no primarily anti-fibrotic medications are currently used to treat patients with heart failure (HF). Pirfenidone is an oral antifibrotic agent approved for the treatment of idiopathic pulmonary fibrosis. Although its exact mechanism of action is not fully understood, pirfenidone might reduce the expression of profibrotic factors such as transforming growth factor-β (TGF-β), and proinflammatory cytokines, like tumor necrosis factor-α (TNF-α), interleukin (IL)-4, and IL-13, which could modulate the inflammatory response and inhibit collagen synthesis in lung tissue. There is some evidence that pirfenidone has antifibrotic activity in various animal models of cardiac disease. Furthermore, the positive results of the PIROUETTE trial, evaluating pirfenidone in patients with HF with preserved ejection fraction, have been very recently announced. This review summarizes the data about pirfenidone as a potential cardioprotective treatment.

Cardiac MRI findings in patients with Crohn's disease

BACKGROUND

Early cardiac death is more common in patients with Crohn's disease (CD) than in healthy adults, but the exact cause is unknown.

AIMS

The aim of this study is to investigate the cardiac magnetic resonance imaging (MRI) findings in patients with CD and compare the MRI findings with healthy controls (HCs). This study also aimed to demonstrate the possible cardiac involvement in patients with CD using MRI.

METHODS

In this prospective study, participants with CD (n = 20) and HC (n = 20) underwent cardiac MRI. Erythrocyte sedimentation rate (ESR) and hematocrit levels were investigated before MRI in both groups. Two observers evaluated the ventricular functional and morphological parameters in consensus. Myocardial T1/T2-relaxation times were calculated by two observers independently using two different software, and hematocrit-corrected left ventricle extracellular volume (LV-ECV) was calculated. Observer-2 also performed histogram analysis for T1/T2-mapping images.

RESULTS

Patients with CD had a significantly higher LV-ECV, mildly decreased right ventricle ejection fraction, and prolonged T2-relaxation time than HC. Moreover, histogram analysis showed that the maximum and mean T2-relaxation times were higher in patients with CD. There was an excellent agreement between observers for the assessment of mean native and post-contrast T1-relaxation time (intraclass correlation coefficient (ICC) of 0.991 and ICC of 0.941, respectively) and mean T2-relaxation time measurements (ICC of 0.983). Moreover, mean T2-relaxation time was found to be significantly correlated with ESR.

CONCLUSIONS

This study suggests visually undetectable myocardial involvement due to chronic systemic inflammation in patients with Crohn's disease. Cardiac MRI can help assess and monitor cardiac involvement in patients with CD.

Acute heart failure due to dilated cardiomyopathy exacerbated by systemic parechovirus A1 infection in an infant

Parechovirus A1 (PeV-A1) often causes mild respiratory or gastrointestinal disease. Herein we report a case of acute heart failure due to dilated cardiomyopathy exacerbated by acute PeV-A1 infection in a 10-month-old infant. He was brought to our hospital with acute respiratory distress and compensated shock. Echocardiogram showed a dilated left ventricle and severe mitral regurgitation, consistent with dilated cardiomyopathy. PeV-A1 infection was confirmed by (1) positive PCR test results for PeV-A in multiple anatomical sites, including blood, stool, and throat, (2) the genetic sequence of viral protein, and (3) an increase in paired serum PeV-A1-specific neutralizing antibody titers. A few, scattered case reports in infants and young children also indicate the association between myocarditis and/or dilated cardiomyopathy and PeV-A1 infection. In conclusion, PeV-A1 infection could be associated with exacerbation of myocardial diseases in infants and young children; thus PeV-A1 needs to be evaluated as a viral cause of such a condition.

[Transesophageal echocardiography in emergency and intensive care medicine : Indication and implementation]

Transesophageal echocardiography (TEE) in emergency and intensive care medicine represents an additional semi-invasive method to confirm or rebut suspected diagnoses in critically ill patients. Three-dimensional (3D)-TEE investigations are established in the clinical workflow of emergency and intensive care units because 3D-TEE investigations permit a differentiation of artifacts due to oblique views by simultaneous documentation of sectional planes and en face views of characteristic cardiac structures. Thus, the level of diagnostic validity can be significantly increased by 3D-TEE investigation. The main indications of TEE investigation in emergency medicine are hemodynamic instability due to myocardial, pericardial or valvular heart diseases as well as suspected endocarditis and aortic dissection.

[Effects and mechanisms of ursodeoxycholic acid on isoprenaline-Induced myocardial fibrosis in mice]

Objective: To investigate the effects and possible mechanisms of ursodeoxycholic acid (UDCA) on myocardial fibrosis in mice. Method: To observe the expression of transforming growth factor(TGF) -β1, CTGF, MMPs and the degree of myocardial fibrosis, 61 male Kunming mice were randomly divided into normal group, low dose UDCA group, high dose of UDCA group, spironolactone group, and the control group.Isoproterenol (ISO) injection was given subcutaneously (30 d) to make the model of myocardial fibrosis.Corresponding anti-fibrosis drugs (UDCA or spironolactone) were given by gavage.HE staining and Masson staining were performed to explore the inflammation and fibrosis in the myocardium.The expression of collagen Ⅰ and collagen Ⅲ protein was detected by immunohistochemistry to evaluate the degree of fibrosis among the groups.Western blot was used to detect the expression of transforming growth factor, (TGF)-β1, connective tissue growth factor (CTGF), matrix metalloproteinase (MMP)-2, -9, tissue inhibitor of metalloproteinase (TIMP)-4, -1 and anti-phospho-NFKBIA (p-IκB-α) inhibitor of NF-κB (IκB) protein in myocardium. Results: HE and Masson staining results showed that in the normal group, myocardial fibrosis is less, while the control group showed a large amount of fibrotic tissue (P<0.05). Tissue fibrosis in the low/high dose UDCA group and spironolactone group was significantly reduced compared with the control group (P<0.05), in which high dose of UDCA reduces fibrosis more significantly.Immunohistochemistry results showed that collagen Ⅰ and collagen Ⅲ protein expression was significantly increased (P<0.05). Whereas in the low/high UDCA dose group and spironolactone group, collagen Ⅰ and collagen Ⅲ expression were significantly decreased (P<0.05), the high UDCA dose group decreased more significantly.Western blot results suggest that TGFβ-1 expression in the myocardial tissue was significantly increased compared to the normal group (P<0.05), whereas low/high UDCA dose group and spironolactone group, TGFβ-1 protein expression were significantly decreased [UDCA(1.52±0.16), (1.02±0.12), (1.01±0.21)vs (2.73±0.12), P<0.05], in which high UDCA dose group TGFβ-1 protein expression level decreased more significantly.However, there was no significant difference in the expression of CTGF, MMP2/9 and TIMP1/4 protein among the groups (P>0.05). UDCA decrease p-IκB-α expression and increase IκB protein expression dose-dependently. Conclusions: UDCA can relieve isoproterenol induced myocardial fibrosis and reduce the myocardial collagen Ⅰ and collagen Ⅲ deposition in a dose dependent manner.Down-regulating of TGFβ-1 protein expression through the inhibition of TGR5-NF-κB signal transduction pathway might be a potential mechanism underlying UDCA's effects.

Coronary microvascular dysfunction: an update

Many patients undergoing coronary angiography because of chest pain syndromes, believed to be indicative of obstructive atherosclerosis of the epicardial coronary arteries, are found to have normal angiograms. In the past two decades, a number of studies have reported that abnormalities in the function and structure of the coronary microcirculation may occur in patients without obstructive atherosclerosis, but with risk factors or with myocardial diseases as well as in patients with obstructive atherosclerosis; furthermore, coronary microvascular dysfunction (CMD) can be iatrogenic. In some instances, CMD represents an epiphenomenon, whereas in others it is an important marker of risk or may even contribute to the pathogenesis of cardiovascular and myocardial diseases, thus becoming a therapeutic target. This review article provides an update on the clinical relevance of CMD in different clinical settings and also the implications for therapy.