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Background: The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) compared an initial invasive versus an initial conservative management strategy for patients with chronic coronary disease and moderate or severe ischemia, with no major difference in most outcomes during a median of 3.2 years. Extended follow-up for mortality is ongoing. Methods: ISCHEMIA participants were randomized to an initial invasive strategy added to guideline-directed medical therapy or a conservative strategy. Patients with moderate or severe ischemia, ejection fraction ≥35%, and no recent acute coronary syndromes were included. Those with an unacceptable level of angina were excluded. Extended follow-up for vital status is being conducted by sites or through central death index search. Data obtained through December 2021 are included in this interim report. We analyzed all-cause, cardiovascular, and noncardiovascular mortality by randomized strategy, using nonparametric cumulative incidence estimators, Cox regression models, and Bayesian methods. Undetermined deaths were classified as cardiovascular as prespecified in the trial protocol. Results: Baseline characteristics for 5179 original ISCHEMIA trial participants included median age 65 years, 23% women, 16% Hispanic, 4% Black, 42% with diabetes, and median ejection fraction 0.60. A total of 557 deaths accrued during a median follow-up of 5.7 years, with 268 of these added in the extended follow-up phase. This included a total of 343 cardiovascular deaths, 192 noncardiovascular deaths, and 22 unclassified deaths. All-cause mortality was not different between randomized treatment groups (7-year rate, 12.7% in invasive strategy, 13.4% in conservative strategy; adjusted hazard ratio, 1.00 [95% CI, 0.85–1.18]). There was a lower 7-year rate cardiovascular mortality (6.4% versus 8.6%; adjusted hazard ratio, 0.78 [95% CI, 0.63–0.96]) with an initial invasive strategy but a higher 7-year rate of noncardiovascular mortality (5.6% versus 4.4%; adjusted hazard ratio, 1.44 [95% CI, 1.08–1.91]) compared with the conservative strategy. No heterogeneity of treatment effect was evident in prespecified subgroups, including multivessel coronary disease. Conclusions: There was no difference in all-cause mortality with an initial invasive strategy compared with an initial conservative strategy, but there was lower risk of cardiovascular mortality and higher risk of noncardiovascular mortality with an initial invasive strategy during a median follow-up of 5.7 years. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04894877.

Background: Effective diuretic regimens using loop diuretics in patients with acute decompensated heart failure are often limited by the development of worsening kidney function. Sodium-glucose cotransporter-2 inhibitors induce glucosuria and sodium excretion with nephroprotective effects in patients with stable heart failure but their role in acute decompensated heart failure is unclear. Methods: In this single-center, prospective, double-blind, placebo-controlled, randomized study, we randomly assigned patients with acute decompensated heart failure to empagliflozin 25 mg daily or placebo in addition to standard decongestive treatments that included loop diuretics. The primary end point was cumulative urine output over 5 days. Secondary end points included diuretic efficiency, dynamics in markers of kidney function and injury, and NT-proBNP (N-terminal pro-B-type natriuretic peptide). Results: Sixty patients were randomized within 12 hours of hospitalization for acute decompensated heart failure. Addition of empagliflozin daily to standard medical treatment of acute decompensated heart failure resulted in a 25% increase in cumulative urine output over 5 days (median 10.8 versus 8.7 L mL in placebo, group difference estimation 2.2 L [95% CI, 8.4 to 3.6]; P =0.003). Empagliflozin increased diuretic efficiency compared with placebo (14.1 mL urine per milligram furosemide equivalent [95% CI, 0.6–27.7]; P =0.041) without affecting markers of renal function (estimated glomerular filtration rate, 51±19 versus 54±17 mL/min per 1.73 m²; P =0.599) or injury (total urinary protein, 492±845 versus 503±847 mg/g creatinine; P =0.975; and urinary α1-microglobulin, 55.4±38.6 versus 31.3±33.6 mg/g creatinine; P =0.066) with more pronounced decrease in NT-proBNP in the empagliflozin group compared with placebo (−1861 versus −727.2 pg/mL after 5 days; quotient in slope, 0.89 [95% CI, 0.83–0.95]; P Conclusions: Early addition of empagliflozin to standard diuretic therapy increases urine output without affecting renal function in patients with acute decompensated heart failure. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04049045.

Background: We previously showed that cardiomyocyte Krϋppel-like factor (KLF) 5 regulates cardiac fatty acid oxidation. As heart failure has been associated with altered fatty acid oxidation, we investigated the role of cardiomyocyte KLF5 in lipid metabolism and pathophysiology of ischemic heart failure. Methods: Using real-time polymerase chain reaction and Western blot, we investigated the KLF5 expression changes in a myocardial infarction (MI) mouse model and heart tissue from patients with ischemic heart failure. Using 2D echocardiography, we evaluated the effect of KLF5 inhibition after MI using pharmacological KLF5 inhibitor ML264 and mice with cardiomyocyte-specific KLF5 deletion (αMHC [α-myosin heavy chain]-KLF5 −/ − ). We identified the involvement of KLF5 in regulating lipid metabolism and ceramide accumulation after MI using liquid chromatography–tandem mass spectrometry, and Western blot and real-time polymerase chain reaction analysis of ceramide metabolism–related genes. We lastly evaluated the effect of cardiomyocyte-specific KLF5 overexpression (αMHC-rtTA [reverse tetracycline-controlled transactivator]-KLF5) on cardiac function and ceramide metabolism, and rescued the phenotype using myriocin to inhibit ceramide biosynthesis. Results: KLF5 mRNA and protein levels were higher in human ischemic heart failure samples and in rodent models at 24 hours, 2 weeks, and 4 weeks post–permanent left coronary artery ligation. αMHC-KLF5 −/− mice and mice treated with ML264 had higher ejection fraction and lower ventricular volume and heart weight after MI. Lipidomic analysis showed that αMHC-KLF5 −/ − mice with MI had lower myocardial ceramide levels compared with littermate control mice with MI, although basal ceramide content of αMHC-KLF5 −/ − mice was not different in control mice. KLF5 ablation suppressed the expression of SPTLC1 and SPTLC2 (serine palmitoyltransferase [SPT] long-chain base subunit ()1 2, respectively), which regulate de novo ceramide biosynthesis. We confirmed our previous findings that myocardial SPTLC1 and SPTLC2 levels are increased in heart failure patients. Consistently, αMHC-rtTA-KLF5 mice showed increased SPTLC1 and SPTLC2 expression, higher myocardial ceramide levels, and systolic dysfunction beginning 2 weeks after KLF5 induction. Treatment of αMHC-rtTA-KLF5 mice with myriocin that inhibits SPT, suppressed myocardial ceramide levels and alleviated systolic dysfunction. Conclusions: KLF5 is induced during the development of ischemic heart failure in humans and mice and stimulates ceramide biosynthesis. Genetic or pharmacological inhibition of KLF5 in mice with MI prevents ceramide accumulation, alleviates eccentric remodeling, and increases ejection fraction. Thus, KLF5 emerges as a novel therapeutic target for the treatment of ischemic heart failure.

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used to treat cardiogenic shock. However, VA-ECMO might hamper myocardial recovery. The Impella unloads the left ventricle. This study aimed to evaluate whether left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO was associated with lower mortality. Methods: Data from 686 consecutive patients with cardiogenic shock treated with VA-ECMO with or without left ventricular unloading using an Impella at 16 tertiary care centers in 4 countries were collected. The association between left ventricular unloading and 30-day mortality was assessed by Cox regression models in a 1:1 propensity score–matched cohort. Results: Left ventricular unloading was used in 337 of the 686 patients (49%). After matching, 255 patients with left ventricular unloading were compared with 255 patients without left ventricular unloading. In the matched cohort, left ventricular unloading was associated with lower 30-day mortality (hazard ratio, 0.79 [95% CI, 0.63–0.98]; P =0.03) without differences in various subgroups. Complications occurred more frequently in patients with left ventricular unloading: severe bleeding in 98 (38.4%) versus 45 (17.9%), access site–related ischemia in 55 (21.6%) versus 31 (12.3%), abdominal compartment in 23 (9.4%) versus 9 (3.7%), and renal replacement therapy in 148 (58.5%) versus 99 (39.1%). Conclusions: In this international, multicenter cohort study, left ventricular unloading was associated with lower mortality in patients with cardiogenic shock treated with VA-ECMO, despite higher complication rates. These findings support use of left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO and call for further validation, ideally in a randomized, controlled trial.

Background: Cardiac surgery often represents the only treatment option in patients with infective endocarditis (IE). However, IE surgery may lead to a sudden release of inflammatory mediators, which is associated with postoperative organ dysfunction. We investigated the effect of hemoadsorption during IE surgery on postoperative organ dysfunction. Methods: This multicenter, randomized, nonblinded, controlled trial assigned patients undergoing cardiac surgery for IE to hemoadsorption (integration of CytoSorb to cardiopulmonary bypass) or control. The primary outcome (change in sequential organ failure assessment score [ΔSOFA]) was defined as the difference between the mean total postoperative SOFA score, calculated maximally to the 9th postoperative day, and the basal SOFA score. The analysis was by modified intention to treat. A predefined intergroup comparison was performed using a linear mixed model for ΔSOFA including surgeon and baseline SOFA score as fixed effect covariates and with the surgical center as random effect. The SOFA score assesses dysfunction in 6 organ systems, each scored from 0 to 4. Higher scores indicate worsening dysfunction. Secondary outcomes were 30-day mortality, duration of mechanical ventilation, and vasopressor and renal replacement therapy. Cytokines were measured in the first 50 patients. Results: Between January 17, 2018, and January 31, 2020, a total of 288 patients were randomly assigned to hemoadsorption (n=142) or control (n=146). Four patients in the hemoadsorption and 2 in the control group were excluded because they did not undergo surgery. The primary outcome, ΔSOFA, did not differ between the hemoadsorption and the control group (1.79±3.75 and 1.93±3.53, respectively; 95% CI, –1.30 to 0.83; P =0.6766). Mortality at 30 days (21% hemoadsorption versus 22% control; P =0.782), duration of mechanical ventilation, and vasopressor and renal replacement therapy did not differ between groups. Levels of interleukin-1β and interleukin-18 at the end of integration of hemoadsorption to cardiopulmonary bypass were significantly lower in the hemoadsorption than in the control group. Conclusions: This randomized trial failed to demonstrate a reduction in postoperative organ dysfunction through intraoperative hemoadsorption in patients undergoing cardiac surgery for IE. Although hemoadsorption reduced plasma cytokines at the end of cardiopulmonary bypass, there was no difference in any of the clinically relevant outcome measures. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03266302.

Background: Metabolic remodeling in heart failure contributes to dysfunctional lipid trafficking and lipotoxicity. Acyl coenzyme A synthetase-1 (ACSL1) facilitates long-chain fatty acid (LCFA) uptake and activation with coenzyme A (CoA), mediating the fate of LCFA. The authors tested whether cardiac ACSL1 overexpression aids LCFA oxidation and reduces lipotoxicity under pathological stress of transverse aortic constriction (TAC). Methods: Mice with cardiac restricted ACSL1 overexpression (MHC-ACSL1) underwent TAC or sham surgery followed by serial in vivo echocardiography for 14 weeks. At the decompensated stage of hypertrophy, isolated hearts were perfused with 13 C LCFA during dynamic-mode 13 C nuclear magnetic resonance followed by in vitro nuclear magnetic resonance and mass spectrometry analysis to assess intramyocardial lipid trafficking. In parallel, acyl CoA was measured in tissue obtained from heart failure patients pre- and postleft ventricular device implantation plus matched controls. Results: TAC-induced cardiac hypertrophy and dysfunction was mitigated in MHC-ACSL1 hearts compared with nontransgenic hearts. At 14 weeks, TAC increased heart weight to tibia length by 46% in nontransgenic mice, but only 26% in MHC-ACSL1 mice, whereas ACSL1 mice retained greater ejection fraction (ACSL1 TAC: 65.8±7.5%; nontransgenic TAC: 45.9±7.3) and improvement in diastolic E/E’. Functional improvements were mediated by ACSL1 changes to cardiac LCFA trafficking. ACSL1 accelerated LCFA uptake, preventing C16 acyl CoA loss post-TAC. Long-chain acyl CoA was similarly reduced in human failing myocardium and restored to control levels by mechanical unloading. ACSL1 trafficked LCFA into ceramides without normalizing the reduced triglyceride storage in TAC. ACSL1 prevented de novo synthesis of cardiotoxic C16- and C24-, and C24:1 ceramides and increased potentially cardioprotective C20- and C22-ceramides post-TAC. ACLS1 overexpression activated AMP activated protein kinase at baseline, but during TAC, prevented the reduced LCFA oxidation in hypertrophic hearts and normalized energy state (phosphocreatine:ATP) and consequently, AMP activated protein kinase activation. Conclusions: This is the first demonstration of reduced acyl CoA in failing hearts of humans and mice, and suggests possible mechanisms for maintaining mitochondrial oxidative energy metabolism by restoring long-chain acyl CoA through ASCL1 activation and mechanical unloading. By mitigating cardiac lipotoxicity, via redirected LCFA trafficking to ceramides, and restoring acyl CoA, ACSL1 delayed progressive cardiac remodeling and failure.

Background: Heart failure leads to mitochondrial dysfunction and metabolic abnormalities of the failing myocardium coupled with an energy-depleted state and cardiac remodeling. The mitochondrial deacetylase sirtuin 3 (SIRT3) plays a pivotal role in the maintenance of mitochondrial function through regulating the mitochondrial acetylome. It is interesting to note that unique cardiac and systemic microRNAs have been shown to play an important role in cardiac remodeling by modulating key signaling elements in the myocardium. Methods: Cellular signaling was analyzed in human cardiomyocyte-like AC16 cells, and acetylation levels in rodent models of SIRT3 –/– and transgenic microRNA-195 (miR-195) overexpression were compared with wild type. Luciferase assays, Western blotting, immunoprecipitation assays, and echocardiographic analysis were performed. Enzymatic activities of pyruvate dehydrogenase (PDH) and ATP synthase were measured. Results: In failing human myocardium, we observed induction of miR-195 along with decreased expression of the mitochondrial deacetylase SIRT3 that was associated with increased global protein acetylation. We further investigated the role of miR-195 in SIRT3-mediated metabolic processes and its impact on regulating enzymes involved in deacetylation. Proteomic analysis of the total acetylome showed increased overall acetylation, and specific lysine acetylation of 2 central mitochondrial metabolic enzymes, PDH and ATP synthase, as well. miR-195 downregulates SIRT3 expression through direct 3′-untranslated region targeting. Treatments with either sirtuin inhibitor nicotinamide, small interfering RNA–mediated SIRT3 knockdown or miR-195 overexpression enhanced acetylation of PDH complex and ATP synthase. This effect diminished PDH and ATP synthase activity and impaired mitochondrial respiration.SIRT3 –/– and miR-195 transgenic mice consistently showed enhanced global protein acetylation, including PDH complex and ATP synthase, associated with decreased enzymatic activity. Conclusions: Altogether, these data suggest that increased levels of miR-195 in failing myocardium regulate a novel pathway that involves direct SIRT3 suppression and enzymatic inhibition via increased acetylation of PDH and ATP synthase that are essential for cardiac energy metabolism.

Background— Heart failure is associated with impaired myocardial metabolism with a shift from fatty acids to glucose use for ATP generation. We hypothesized that cardiac accumulation of toxic lipid intermediates inhibits insulin signaling in advanced heart failure and that mechanical unloading of the failing myocardium corrects impaired cardiac metabolism. Methods and Results— We analyzed the myocardium and serum of 61 patients with heart failure (body mass index, 26.5±5.1 kg/m 2 ; age, 51±12 years) obtained during left ventricular assist device implantation and at explantation (mean duration, 185±156 days) and from 9 control subjects. Systemic insulin resistance in heart failure was accompanied by decreased myocardial triglyceride and overall fatty acid content but increased toxic lipid intermediates, diacylglycerol, and ceramide. Increased membrane localization of protein kinase C isoforms, inhibitors of insulin signaling, and decreased activity of insulin signaling molecules Akt and Foxo were detectable in heart failure compared with control subjects. Left ventricular assist device implantation improved whole-body insulin resistance (homeostatic model of analysis–insulin resistance, 4.5±0.6–3.2±0.5; P Conclusions— Mechanical unloading after left ventricular assist device implantation corrects systemic and local metabolic derangements in advanced heart failure, leading to reduced myocardial levels of toxic lipid intermediates and improved cardiac insulin signaling.

Fatty acids (FAs) are the primary source for cardiac energy utilization. They account for 70% of myocardial ATP production and glucose; lactate and ketones account for the remaining 30%.1 Earlier studies have suggested that esterified FAs are the major source of cardiac lipids in humans.2 A significant portion of FAs utilized by the heart are derived from dietary fat, whereas the rest are derived from hepatic FAs synthesized from carbohydrates and FAs released after peripheral adipose tissues through lipolysis. Circulating FAs either are esterified to glycerol as a component of lipoprotein triglycerides and phospholipids or circulate as nonesterified free FAs bound to albumin. Palmitic acid (PA) and oleic acid (OA) are the main dietary FAs. Article see p 1790 Free FAs or lipoprotein-derived FAs are taken up primarily by cardiomyocytes via the FA transporter CD36. The fate of FAs after their import into cardiomyocytes has not been fully elucidated. Whether FAs are directly channeled to mitochondria for β oxidation and ATP production or whether storage in intracellular triglycerides and subsequent lipolysis precede FA utilization in mitochondria is a topic of ongoing investigation. Cardiac FA oxidation is centrally regulated by a transcriptional factor of the nuclear receptor family, peroxisome proliferator-activated receptor-α (PPARα). PPARα, similar to the other 2 PPAR isoforms, PPARγ and PPARδ, is activated by FAs and controls the expression of several genes that in …

Introduction: Exosomes are cell-derived vesicles in the extracellular environment present in biological fluids. Exosomal content is actively assembled containing mRNA, miRNA and proteins. Exosomal-derived molecules have messenger function on target cells. Hypothesis: The serum-derived exosomal proteome is altered in acute cardiac allograft rejection allowing a distinction between non-rejection and acute rejection episodes with specifics for the type of rejection. Methods: Serum samples were collected from heart transplant (HTx) recipients with no rejection (n=10), acute cellular rejection (n=10) and antibody-mediated rejection (n=8) confirmed by myocardial biopsy and histopathology report. Exosome isolation was performed using an isolation kit (Invitrogen). Proteomic analyses were performed by LC-MS/MS analysis using the Fusion Tribrid Orbitrap Mass Spectrometer. To confirm these findings, one of the proteins found by proteomic analysis, C1Q, was compared across samples with ELISA (Abcam). Results: A distinct pattern was detectable separating each group by clustering analysis. A exosomal protein signature totaling 24 proteins (FDR Conclusions: These data suggest a distinct exosomal proteome signature in cardiac allograft rejection patients as compared to patients without rejection, mainly involving complement cascade proteins, immunoglobulin fractions and structural proteins. Exosomal proteome analysis shows potential for non-invasive characterization of cardiac allograft rejection with distinct profiles in patients with ACR and AMR.

Mechanical assist devices have emerged as an established therapeutic option for patients with end-stage heart failure. Predicting which patients are unlikely to benefit from continuous flow left ventricular assist device (cf-LVAD) treatment is crucial for the identification of appropriate patients while excluding those considered futile. Previously developed scoring systems are limited to prior eras of device and medical support or restricted to specific devices. Methods: We performed a retrospective analysis of all patients implanted with a cf-LVAD (Heartmate II or HVAD) at our institution between 2005 and 2014. From all plausible pre-operative covariates, we performed univariate Cox regression analysis for covariates affecting the odds of 1yr post implantation survival (p Results: A total of 204 patients (male 78%; mean age 57+15, mean follow up 465+486 days). After stepwise selection for variables that increased predictive power, a final optimized model was identified (Figure). One yr survival was significantly lower in patients with higher risk score (HR 2.48, p= Conclusion: We present a novel risk score and its validation for prediction of long-term survival in patients on cf-LVAD support. This score may prove useful for patient selection and identification of patients requiring adjuvant therapies

Background: Heart failure (HF) is a multi-organ, pro-inflammatory syndrome that impairs bone metabolism. Proinflammatory cytokines and bone catabolism enhance periodontal disease, a local inflammatory, bacteria-induced disease that causes bone loss and periodontal soft tissue destruction. Hypothesis: Patients with advanced HF before and after heart transplantation (HTx) have more severe periodontal disease as compared to age and smoking-matched controls. Further, local inflammatory markers in the saliva and gingival crevicular fluid (GCF) can be used as markers of the local inflammatory periodontal burden in patients with HF. Methods: Medical and dental examinations were performed on patients with HF (n=41), following heart transplantation (post-HTx, n=40) and controls (n=32). Blood, saliva and GCF samples were taken to investigate markers of bone metabolism and inflammation. Results: Average New York Heart Association classification for HF was class III. Average time since HTx was 33.14 months. Overall periodontal diagnosis was more severe in patients with advanced HF and post-HTx versus controls (p Conclusion: Patients with advanced HF exhibit more severe periodontal disease associated with increased bone turnover markers when compared to control patients. Further, periodontal disease severity was detectable in saliva and GCF making it a potential useful tool for identifying the need for periodontal treatment in patients with advanced HF.

Background— Although cellular redox balance plays an important role in mechanically induced cardiac hypertrophy, the mechanisms of regulation are incompletely defined. Because thioredoxin is a major intracellular antioxidant and can also regulate redox-dependent transcription, we explored the role of thioredoxin activity in mechanically overloaded cardiomyocytes in vitro and in vivo. Methods and Results— Overexpression of thioredoxin induced protein synthesis in cardiomyocytes (127±5% of controls, P P P P P P P Conclusions— Thus, even though thioredoxin is an antioxidant, activation of thioredoxin participates in the development of pressure-overload cardiac hypertrophy, demonstrating the dual function of thioredoxin as both an antioxidant and a signaling protein. These results also support the emerging concept that the thioredoxin inhibitor Txnip is a critical regulator of biomechanical signaling.

Background— Embryonic stem (ES) cells are capable of self-renewal and differentiation into cellular derivatives of all 3 germ layers. In appropriate culture conditions, ES cells can differentiate into specialized cells, including cardiac myocytes, but the efficiency is typically low and the process is incompletely understood. Methods and Results— We evaluated a chemical library for its potential to induce cardiac differentiation of ES cells in the absence of embryoid body formation. Using ES cells stably transfected with cardiac-specific α-cardiac myosin heavy chain (MHC) promoter-driven enhanced green fluorescent protein (EGFP), 880 compounds approved for human use were screened for their ability to induce cardiac differentiation. Treatment with ascorbic acid, also known as vitamin C, markedly increased the number of EGFP-positive cells, which displayed spontaneous and rhythmic contractile activity and stained positively for sarcomeric myosin and α-actinin. Furthermore, ascorbic acid induced the expression of cardiac genes, including GATA4, α-MHC, and β-MHC in untransfected ES cells in a developmentally controlled manner. This effect of ascorbic acid on cardiac differentiation was not mimicked by the other antioxidants such as N-acetylcysteine, Tiron, or vitamin E. Conclusions— Ascorbic acid induces cardiac differentiation in ES cells. This study demonstrates the potential for chemically modifying the cardiac differentiation program of ES cells.

Krüppel-like factors (KLF) affect metabolism. Lipopolysaccharide-induced sepsis reduced cardiac PPARα and increased KLF5 (8-fold) more than any cardiac KLF isoform detected by whole genome microarray analysis. In silico analysis of ppara gene promoter predicted two KLF5 binding sites that overlap with c-Jun (AP-1) binding sites: -792/-772 bp and -719/-698 bp. Infection of a mouse cardiomyocyte cell line (HL-1) with adenovirus expressing constitutively active c-Jun reduced, while Ad-KLF5 increased PPARα mRNA in a dose-dependent manner. Chromatin immunoprecipitation (ChIP) showed that c-Jun binds both -792/-772 bp and -719/-698 on ppara promoter while KLF5 binds on -792/-772 bp. ChIP on LPS-treated HL-1 cells showed that c-Jun binding on -792/-772 bp prohibits KLF5 binding. We generated a cardiomyocyte-specific KLF5 knockout mouse (αMHC-KLF5-/-), which had 50% normal cardiac function. Cardiomyocyte-specific KLF5 ablation reduced PPARα (50%) and several fatty acid metabolism-associated genes such as CD36 (40%), LpL (20%), PGC1α (45%), AOX (28%) and Cpt1 (45%). As PPARα regulates cardiac fatty acid metabolism, we tested whether cardiac KLF5 is modulated in diabetes, when cardiac PPARα and lipid changes occur. I.p. injection of streptozotocin (STZ) in C57BL/6 mice increased plasma glucose (2.9-fold) and reduced cardiac KLF5 and PPARα gene expression; similar to STZ-treated rats but unlike what had been found in a different mouse strain (C57BL/6 x DBA2) treated with STZ. Treatment of HL-1 cells with increased glucose-containing medium (1 mg/ml) reduced KLF5 (80%) and PPARα (65%), as well as fatty acid metabolism markers, such as AOX (85%), Cpt1β (70%), LCAD (80%) and VLCAD (85%). On the other hand GLUT1 and GLUT4 were increased (30% and 20%) and PDK4 was reduced (65%) indicating increased glucose utilization. A model of non-insulin dependent hyperglycemia (ob/ob mice) had reduced cardiac KLF5 (60%) and PPARα (65%). Correction of hyperglycemia in STZ-treated C57BL/6 mice by pharmacological (dapagliflozin) or antisense oligonucleotide inhibition of kidney’s sodium glucose transporter 2 (SGLT2), restored KLF5 and PPARα gene expression. Thus, KLF5 is a transcriptional regulator of cardiac PPARα that is driven by changes in plasma glucose levels

Introduction: Many heart failure (HF) associated non-histone proteins are modified by post-translational lysine acetylation which regulates protein activity and affects cardiac function. Hypothesis: We hypothesized that acetylation of mitochondrial proteins involved in cardiac metabolism mediate metabolic changes in the failing myocardium. We focused on pyruvate dehydrogenase (PDH) which converts pyruvate, the end-product of glycolysis, to acetyl-CoA, a substrate of the citric acid cycle. Methods: Human myocardial tissue from HF patients, failing rodent myocardium after transverse aortic constriction (TAC) induced pressure-overload HF and human cardiomyocyte-like AC16 cells were used. Western Blot, immunoprecipitation assays and mass spectrometry were performed to analyze protein expression and acetylation levels. Results: In our studies, we observed a significant increase in overall cardiac protein acetylation in both HF patients (5.8-fold, p Conclusions: Together, our data suggest that increased acetylation of PDH due to reduced SirT3 expression in HF contributes to altered mitochondrial substrate metabolism and is associated with cardiac dysfunction. These findings suggest a novel role for acetylation of PDH in the failing myocardium.

Patients with chronic heart failure (HF) develop metabolic abnormalities including a catabolic state, weight loss and cachexia that are associated with adipocyte dysregulation. Several factors, such as inflammatory cytokines and neurohormones, that regulate adipocytes are known to be elevated in ADHF. Therefore, we hypothesized that in acute decompensation (ADHF) there is marked dysregulation of adipocyte function as reflected by circulating adipocytokines including visfatin, a recently described adipocytokine. Methods: Plasma was obtained from 41 patients with ADHF (EF 27 ± 14, BMI 32 ± 6), 25 patients with chronic stable HF (EF 27 ± 18, BMI 28 ± 5), and 21 control subjects (EF 63 ± 3, BMI 31 ± 6) without HF. Levels of NT-proBNP, visfatin, adiponectin, resistin, leptin, insulin, IGF-1 and TNFα were measured by ELISA. Insulin resistance was assessed by HOMA-IR quotient. Results: NT-proBNP was 330 ± 28 fmol/mL in control (Con) patients, elevated to 704 ± 86 fmol/mL in chronic HF and elevated further to 1774 ± 206 fmol/mL in ADHF. Adiponectin was 14.9 ± 3 ng/mL in Con, increased to 28.9 ± 5.7 (p < 0.05) in stable HF, and increased further to 42.9 ± 2.8 ng/mL in ADHF (p < 0.05). Likewise, visfatin was 16.9 ± 3.5 ng/mL in Con, increased to 43.4 ± 9.5 (p < 0.05) in stable HF, and increased further to 79.9 ± 4.6 ng/mL ng/mL in ADHF (p < 0.05). Leptin and resistin were not elevated in chronic stable HF, whereas in ADHF, leptin (9.6 ± 1.0 vs 3.7 ± 0.6 ng/mL; p < 0.0001) and resistin (11.6 ± 1.3 vs 5.7 ± 0.9 ng/mL; p < 0.01) were both elevated compared to Con. Insulin resistance was present in chronic stable HF (24.5 ± 2.2 μU/mL*mg/dL) and increased further in ADHF (32.9 ± 2.0 vs; p < 0.001 vs. Con). In contrast, IGF-1 or insulin were unchanged in the three groups. In patients with ADHF, visfatin, resistin and insulin resistance all correlated with TNFα (p < 0.05 for all). Conclusion: In ADHF there is marked dysregulation of adipocytes as evidenced by elevated blood levels of several adipocytokines, including adiponectin, visfatin, leptin and resistin, and paralleled by worsening insulin resistance. TNFα may contribute to both adipocyte dysregulation and insulin resistance. Metabolic dysfunction in ADHF is associated with elevated adipocytokines that have important effects on insulin signaling.