Cardinal pathologic features of hypertensive heart disease (HHD) include not only hypertrophied cardiomyocytes and foci of scattered microscopic scarring, a footprint of prior necrosis, but also small myocytes ensnared by fibrillar collagen where disuse atrophy with protein degradation would be predicted. Whether atrophic signaling is concordant with the appearance of HHD and involves oxidative and endoplasmic reticulum (ER) stress remains unexplored. Herein, we examine these possibilities focusing on the left ventricle (LV) and cardiomyocytes harvested from hypertensive rats receiving 4 wks aldosterone/salt treatment (ALDOST) alone or together with ZnSO4, a nonvasoactive antioxidant, with the potential to attenuate atrophy and optimize hypertrophy. Compared to untreated age-/sex-/strain-matched controls, ALDOST was accompanied by: a) LV hypertrophy with preserved systolic function; b) concordant cardiomyocyte atrophy (<1000 μm2) found at sites bordering on fibrosis where they were re-expressing β-myosin heavy chain; and c) upregulation of ubiquitin ligases, MuRF1 and atrogin-1, and elevated 8-isoprostane and unfolded protein ER response with mRNA upregulation of stress markers. ZnSO4 cotreatment reduced lipid peroxidation, fibrosis and the number of atrophic myocytes, together with a further increase in cell area and width of atrophied and hypertrophied myocytes, and improved systolic function, but did not attenuate elevated blood pressure. We conclude that atrophic signaling, concordant with hypertrophy, occurs in the presence of a reparative fibrosis and induction of oxidative and ER stress at sites of scarring where myocytes are atrophied. ZnSO4 cotreatment in HHD with ALDOST attenuates the number of atrophic myocytes, optimizes size of atrophied and hypertrophied myocytes, and improves systolic function.
Cardiomyocyte necrosis with attendant microscopic scarring is a pathological feature of human hypertensive heart disease (HHD). Understanding the pathophysiological origins of necrosis is integral to its prevention. In a rat model of HHD associated with aldosterone/salt treatment (ALDOST), myocyte necrosis is attributable to oxidative stress induced by cytosolic-free [Ca]i and mitochondrial [Ca]m overloading in which the rate of reactive oxygen species generation overwhelms their rate of detoxification by endogenous Zn-based antioxidant defenses. We hypothesized that nebivolol (Neb), unlike another β1 adrenergic receptor antagonist atenolol (Aten), would have a multifaceted antioxidant potential based on its dual property as a β3 receptor agonist, which activates endothelial nitric oxide synthase to stimulate nitric oxide (NO) generation. NO promotes the release of cytosolic Zn sequestered inactive by its binding protein, metallothionein. Given the reciprocal regulation between these cations, increased [Zn]i reduces Ca entry and attendant rise in [Ca]i and [Ca]m. Herein, we examined the antioxidant and cardioprotectant properties of Neb and Aten in rats receiving 4 weeks ALDOST. Compared with untreated age-/sex-matched controls, ALDOST alone or ALDOST with Aten, Neb cotreatment induced endothelial nitric oxide synthase activation, NO generation and a marked increase in [Zn]i with associated decline in [Ca]i and [Ca]m. Attendant antioxidant profile at subcellular and cellular levels included attenuation of mitochondrial H2O2 production and lipid peroxidation expressed as reduced 8-isoprostane concentrations in both mitochondria and cardiac tissue. Myocyte salvage was expressed as reduced microscopic scarring and tissue collagen volume fraction. Neb is a multifaceted antioxidant with unique properties as cardioprotectant in HHD.
With the perspective of functional myocardial regeneration, we investigated small cardiomyocytes bordering on microdomains of fibrosis, where they are dedifferentiated re-expressing fetal genes, and determined: i) whether they are atrophied segments of the myofiber syncytium; ii) their redox state; iii) their anatomic relationship to activated myofibroblasts (myoFb), given their putative regulatory role in myocyte dedifferentiation and re-differentiation; iv) the relevance of proteolytic ligases of the ubiquitin-proteasome system (UPS) as a mechanistic link to their size; and v) whether they could be rescued from their dedifferentiated phenotype. Chronic aldosterone/salt treatment (ALDOST) was invoked, where hypertensive heart disease with attendant myocardial fibrosis creates the fibrillar collagen substrate for myocyte sequestration with propensity for disuse atrophy, activated myoFb and oxidative stress. To address phenotype rescue, 4 wks ALDOST was terminated followed by 4 wks neurohormonal withdrawal combined with a regimen of exogenous antioxidants, ZnSO4 and nebivolol (assisted recovery). Compared to controls, at 4 wks ALDOST we found small myocytes to be: 1) sequestered by collagen fibrils emanating from microdomains of fibrosis and representing atrophic segments of the myofiber syncytia; 2) dedifferentiated re-expressing fetal genes (β-myosin heavy chain and atrial natriuretic peptide); 3) proximal to activated myoFb expressing α-smooth muscle actin microfilaments and angiotensin-converting enzyme; 4) expressing reactive oxygen species and nitric oxide (NO) with increased tissue 8-isoprostane, coupled to ventricular diastolic and systolic dysfunction; and 5) associated with upregulated redox-sensitive, proteolytic ligases MuRF1 and atrogin-1. In a separate study, we did not find evidence of myocyte replication (BrdU labeling) or expression of stem cell antigen (c-Kit) at wks 1-4 ALDOST. Assisted recovery caused: complete disappearance of myoFb from sites of fibrosis with re-differentiation of these myocytes; loss of oxidative stress and UPS activation, with restoration of NO and improved ventricular function. Thus, small dedifferentiated myocytes bordering on microdomains of fibrosis can re-differentiate and represent a potential source of autologous cells for functional myocardial regeneration.
The symptoms and signs constituting the congestive heart failure (CHF) syndrome have their pathophysiologic origins rooted in a salt-avid renal state mediated by effector hormones of the renin-angiotensin-aldosterone and adrenergic nervous systems. Controlled clinical trials, conducted over the past decade in patients having minimally to markedly severe symptomatic heart failure, have demonstrated the efficacy of a pharmacologic regimen that interferes with these hormones, including aldosterone receptor binding with either spironolactone or eplerenone. Potential pathophysiologic mechanisms which have not hitherto been considered involved for the salutary responses and cardioprotection provided by these mineralocorticoid receptor antagonists are reviewed herein. In particular, we focus on the less well-recognized impact of catecholamines and aldosterone on mono- and divalent cation dyshomeostasis which leads to hypokalemia, hypomagnesemia, ionized hypocalcemia with secondary hyperparathyroidism and hypozincemia. Attendant adverse cardiac consequences include a delay in myocardial repolarization with increased propensity for supra- and ventricular arrhythmias and compromised antioxidant defenses with increased susceptibility to nonischemic cardiomyocyte necrosis.
Background: Several risk predictors for stroke in AF patients, specifically the CHADS2 criteria, have been implicated in left ventricular (LV) diastolic dysfunction (DD). It is plausible that DD and subsequent elevation in left ventricular filling pressure (LVFP) mediate stasis within the left atrium leading to thrombus formation and embolic stroke in AF patients. Left atrial volume index (LAVI) is known to correlate with LVFP and AF chronicity. We sought to assess whether LAVI can predict ischemic stroke in patients with AF, independent of clinical risk predictors. Hypothesis: In AF patients, LAVI is associated with ischemic stroke independent of clinical covariates. Methods: We conducted a retrospective case-control study with 203 patients. The case group (n=33) was derived from our institution’s stroke database which was used to identify strokes attributed to an embolic mechanism related to AF as adjudicated by expert neurologist. The control group (n=79) was generated of consecutive AF patients without previous history of stroke. The left atrial dimensions were measured and the left atrial volume (LAVI) was calculated. Binary logistic regression analysis was used to explore whether LAVI predicted stroke independently from CHADS2 score. Results: The mean LAVI in the stroke group was 50.74 s 23.83 in the non-stroke group (p<0.001). Binary logistic regression analysis demonstrated that LAVI was significant as an independent risk factor in addition to the CHADS2 score (OR 1.12, CI: 1.0-1.185 per cc/m2 of volume increment, p<0.001). Subsequently, we developed a novel risk score in which 1 additional point was added to the CHADS2 score for every 5cc increment in the LAVI. The receiver operator characteristics curve analysis showed that the AUC for the novel risk score (LAVI +CHADS2) as a predictor for ischemic stroke to be 0.87 vs 0.74 for the clinical factors alone (p<0.05) Conclusion: Our preliminary data demonstrates that LAVI is an independent risk predictor for embolic stroke in patients with AF. Integrating LAVI with clinical predictors (CHADS2 score) may enhance our ability in predicting stroke and to allow us to better select patients for anticoagulation therapy.
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