Search

Background Little is known about the impacts of sodium glucose co-transporter 2 inhibitors on cardiac functional parameters, such as natriuretic peptides, in type 2 diabetes (T2D) patients with concomitant chronic heart failure (CHF). Purpose To compare the effect of canagliflozin with glimepiride, based on changes in N-terminal pro-brain natriuretic peptide (NT-proBNP), in that patient population. Methods This trial was an investigator-initiated, multicenter, prospective, randomized, open-label, blinded-endpoint trial at 34 centers in Japan. Patients with T2D and clinically stable CHF excluding NYHA class IV, randomized to receive canagliflozin 100 mg or glimepiride (starting dose: 0.5 mg), were examined using the primary endpoint of non-inferiority of canagliflozin versus glimepiride, defined as a margin of 1.1 in the upper-limit of the 2-sided 95% confidence interval (95% CI) for the group ratio of percentage change in NT-proBNP at 24 weeks. Results Data analysis of 233 patients (mean age 68.6±10.1 yrs; 75% male) showed mean left ventricular ejection fraction (LVEF) at randomization was 57.6±14.6%, with 71% of patients having a preserved LVEF (≥50%). The ratio of NT-proBNP percentage change was 0.48 (95% CI, −0.13 to 1.59, P=0.226), and therefore did not meet the prespecified non-inferiority margin. However, data stratified according to baseline NT-proBNP levels showed a trend that canagliflozin treatment reduced NT-proBNP levels to a greater extent than in subgroups with elevated levels of NT-proBNP (Figure A). Furthermore, NT-proBNP levels in the canagliflozin group did show a nonsignificant trend lower in the subgroup with preserved LVEF (Figure B), but not in the subgroup with reduced LVEF (Figure C). Additionally, the changes in the NYHA class were comparable between groups (P=0.061) in the overall cohort, whereas in the subgroup with a preserved LVEF canagliflozin caused a significant improvement in NYHA classes compared to that found for glimepiride treatment (P=0.027). Conclusions This trial did not meet the predefined primary endpoint of changes in NT-proBNP levels, with 24 weeks of treatment with canagliflozin relative to glimepiride which together with other recent studies would question the value of continuing to monitor NT-proBNP levels after the initial diagnosis of heart failure. Nevertheless, in a subgroup with preserved LVEF, there was a non-significant trend for canagliflozin treatment to reduce NT-proBNP levels and improve symptoms even in stable HF patients. Further research is therefore warranted to determine whether patients with preserved LVEF, regardless of diabetes status, could potentially benefit from treatment with SGLT2 inhibitors. Changes in NT-proBNP Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Mitsubishi Tanabe Pharma Corporation

Background Glucagon-like peptide-1 (GLP-1) reduces cardiovascular events in diabetic patients; however, its counter-protective effects have also been suggested in patients with heart failure and the clear explanation for its mechanisms have not yet been offered. Methods The effects of GLP-1 analog on cardiac function and energy metabolism, especially glycemic and lipid metabolisms were elucidated using non-diabetic J2N-k hamsters which showed spontaneous dilated cardiomyopathy. J2N-k hamsters were treated with PBS (HF group), low-dose (HF-L group) or high-dose liraglutide (HF-H group). Results In failing heart, GLP-1 analog exerted further deteriorated cardiac function (e.g. positive and negative dP/dt; p = 0.01 and p = 0.002, respectively) with overt fibrosis and cardiac enlargement (heart/body weight, 5.7 ± 0.2 in HF group versus 7.6 ± 0.2 in HF-H group; p = 0.02). The protein expression of cardiac muscles indicated the energy starvation status. Indirect calorimetry showed that failing hearts consumed higher energy and carbohydrate than normal hearts; moreover, this tendency was augmented by GLP-1 analog administration. Upon 10% glucose solution loading with GLP-1 analog administration (HF-H-G group) as complementary experiments, the cardiac function and fibrosis significantly ameliorated, whereas carbohydrate utilization augmented further and lipid utilization reduced more. The prognosis of HF-H-G group also significantly improved (p = 0.025). Conclusions Glucagon-like peptide-1 analog caused the relative but desperate shortage of glycemic energy source for the failing cardiac muscles and it may restrict ATP synthesis, resulting in cardiac function deterioration. Therefore, appropriate energy supply and amount of carbohydrate intake should be carefully considered when administrating incretin-related drugs to patients with heart failure.

Background Whether a dipeptidyl peptidase-4 (DPP-4) inhibitor can attenuate atherosclerosis is still controversial. Some clinical trials reported that DPP-4 inhibitors in diabetes patients without a previous history of cardiovascular (CV) events could reduce carotid intima-media thickness (IMT). However, in the PROLOGUE study, which enrolled diabetes patients both with and without previous CV events, sitagliptin failed to slow the progression of carotid IMT relative to conventional therapy. Aim and methods We hypothesized that the effect of DPP-4 inhibitors on carotid atherosclerosis might be different between the primary and secondary prevention groups. We performed a post hoc analysis of the PROLOGUE study and compared the effects of sitagliptin and conventional therapy on changes in carotid IMT in subgroups with or without previous CV events. Results No significant difference in the IMT changes between the treatment groups was found in the secondary prevention subgroup (sitagliptin, N = 102; conventional, 111). However, in the primary prevention subgroup (sitagliptin, 120; conventional, 109), we found significant inhibitory effects of sitagliptin on mean and max internal carotid artery IMT [estimated group difference: −0.096 mm (95% CI −0.175 to −0.018, p = 0.017) and −0.162 mm (95% CI −0.272 to −0.052, p = 0.004), respectively], although there was no significant difference in the common carotid artery IMT. Conclusions Our data suggest that there is a favorable effect of DPP-4 inhibitor treatment on carotid atherosclerosis in diabetes patients without previous CV events.

Background An elevated level of serum uric acid (SUA) is associated with an increased risk of cardiovascular disease. Pharmacological intervention with urate-lowering agents, such as the conventional purine analogue xanthine oxidase (XO) inhibitor, allopurinol, has been used widely for a long period of time in clinical practice to reduce SUA levels. Febuxostat, a novel non-purine selective inhibitor of XO, has higher potency for inhibition of XO activity and greater urate-lowering efficacy than conventional allopurinol. However, clinical evidence regarding the effects of febuxostat on atherosclerosis is lacking. The purpose of the study was to test whether treatment with febuxostat delays carotid intima-media thickness (IMT) progression in patients with asymptomatic hyperuricemia. Methods and findings The study was a multicenter, prospective, randomized, open-label, blinded-endpoint clinical trial undertaken at 48 sites throughout Japan between May 2014 and August 2018. Adults with both asymptomatic hyperuricemia (SUA >7.0 mg/dL) and maximum IMT of the common carotid artery (CCA) ≥1.1 mm at screening were allocated equally using a central web system to receive either dose-titrated febuxostat (10–60 mg daily) or as a control-arm, non-pharmacological lifestyle modification for hyperuricemia, such as a healthy diet and exercise therapy. Of the 514 enrolled participants, 31 were excluded from the analysis, with the remaining 483 people (mean age 69.1 years [standard deviation 10.4 years], female 19.7%) included in the primary analysis (febuxostat group, 239; control group, 244), based on a modified intention-to-treat principal. The carotid IMT images were recorded by a single sonographer at each site and read in a treatment-blinded manner by a single analyzer at a central core laboratory. The primary endpoint was the percentage change from baseline to 24 months in mean IMT of the CCA, determined by analysis of covariance using the allocation adjustment factors (age, gender, history of type 2 diabetes, baseline SUA, and baseline maximum IMT of the CCA) as the covariates. Key secondary endpoints included changes in other carotid ultrasonographic parameters and SUA and the incidence of clinical events. The mean values (± standard deviation) of CCA-IMT were 0.825 mm ± 0.173 mm in the febuxostat group and 0.832 mm ± 0.175 mm in the control group (mean between-group difference [febuxostat − control], −0.007 mm [95% confidence interval (CI) −0.039 mm to 0.024 mm; P = 0.65]) at baseline; 0.832 mm ± 0.182 mm in the febuxostat group and 0.848 mm ± 0.176 mm in the control group (mean between-group difference, −0.016 mm [95% CI −0.051 mm to 0.019 mm; P = 0.37]) at 24 months. Compared with the control group, febuxostat had no significant effect on the primary endpoint (mean percentage change 1.2% [95% CI −0.6% to 3.0%] in the febuxostat group (n = 207) versus 1.4% [95% CI −0.5% to 3.3%] in the control group (n = 193); mean between-group difference, −0.2% [95% CI −2.3% to 1.9%; P = 0.83]). Febuxostat also had no effect on the other carotid ultrasonographic parameters. The mean baseline values of SUA were comparable between the two groups (febuxostat, 7.76 mg/dL ± 0.98 mg/dL versus control, 7.73 mg/dL ± 1.04 mg/dL; mean between-group difference, 0.03 mg/dL [95% CI −0.15 mg/dL to 0.21 mg/dL; P = 0.75]). The mean value of SUA at 24 months was significantly lower in the febuxostat group than in the control group (febuxostat, 4.66 mg/dL ± 1.27 mg/dL versus control, 7.28 mg/dL ± 1.27 mg/dL; mean between-group difference, −2.62 mg/dL [95% CI −2.86 mg/dL to −2.38 mg/dL; P < 0.001]). Episodes of gout arthritis occurred only in the control group (4 patients [1.6%]). There were three deaths in the febuxostat group and seven in the control group during follow-up. A limitation of the study was the study design, as it was not a placebo-controlled trial, had a relatively small sample size and a short intervention period, and only enrolled Japanese patients with asymptomatic hyperuricemia. Conclusions In Japanese patients with asymptomatic hyperuricemia, 24 months of febuxostat treatment did not delay carotid atherosclerosis progression, compared with non-pharmacological care. These findings do not support the use of febuxostat for delaying carotid atherosclerosis in this population. Trial registration University Hospital Medical Information Network Clinical Trial Registry UMIN000012911., In a randomized, controlled trial, Atsushi Tanaka and colleagues test whether treatment with febuxostat delays carotid intima-media thickness (IMT) progression in patients with asymptomatic hyperuricemia., Author summary Why was this study done? Elevated levels of serum uric acid (SUA) increase the risk of gout and may be associated with the risk of developing cardiometabolic disorders and subsequent cardiovascular disease. Translational research suggests that urate-lowering therapy by inhibition of xanthine oxidase (XO) may attenuate experimental atherosclerosis. However, the clinical effects of XO inhibitors on atherosclerosis in patients with asymptomatic hyperuricemia remain uncertain. Carotid intima-media thickness (IMT) measurement is a simple and noninvasive method to monitor atherosclerosis. We therefore investigated whether treatment with febuxostat, a non-purine selective inhibitor of XO, delayed the progression of carotid atherosclerosis compared to non-pharmacological care for hyperuricemia in this patient population. What did the researchers do and find? The study was a multicenter, prospective, randomized, open-label, blinded-endpoint clinical trial on 483 eligible participants (mean age 69.1 [standard deviation 10.4], female 19.7%) with asymptomatic hyperuricemia (SUA >7.0 mg/dL) and maximum IMT of the common carotid artery ≥1.1 mm. The results showed that there was no significant difference between febuxostat and non-pharmacological care for hyperuricemia in the progression of carotid atherosclerosis assessed by IMT over 24 months of follow-up. Febuxostat treatment was well tolerated and did not increase the incidence of cardiovascular and all-cause mortality. What do these findings mean? Our findings do not support the use of febuxostat to delay carotid atherosclerosis in patients with asymptomatic hyperuricemia. Further research is needed to determine the effects of febuxostat on atherosclerosis and cardiovascular safety in patients with hyperuricemia irrespective of the presence of gout.

Background: Sodium glucose co-transporter 2 (SGLT2) inhibitors reduce heart failure (HF)-related outcome risk in patients with type 2 diabetes (T2D). However, little is known about the safety and efficacy of SGLT2 inhibitors in patients with T2D and concomitant HF. Methods: CANDLE was an open-label, randomized, parallel-group, multicentre trial at 34 centers in Japan. We randomly assigned (1:1) patients with T2D and New York Heart Association class I-III stable HF to canagliflozin 100 mg once daily or glimepiride (initiation: 0*5 or 1*0 mg daily) by using a computer-generated, dynamic balancing method, stratified by age, HbA1c, and left ventricular ejection fraction, and treated for 24 weeks. Neither patients nor investigators were masked to group assignment, but assessors for the primary endpoint were blinded. The primary endpoint was the non-inferiority of canagliflozin versus glimepiride, with a non-inferiority margin 1*1 in the group ratio of the percentage change in N-terminal pro-brain natriuretic peptide (NT-proBNP) from baseline to 24 weeks. Findings: Between August 10, 2015 and June 30, 2017, 122 patients were assigned to canagliflozin and 123 to glimepiride: 113 in the canagliflozin group and 120 in the glimepiride group were included in the primary endpoint analysis. The group ratio of NT-proBNP percentage changes was 0*48 (95% CI, -0*13 to 1*59, p=0*226). Meanwhile, a group difference in the NT-proBNP absolute change from baseline to 24 weeks was significant (canagliflozin: -107*0 ± 597*8 pg/mL; glimepiride 21*7 ± 252*8, p=0*047). Canagliflozin was well tolerated with adverse events comparable to those of glimepiride. Interpretation: Although the trial did not meet the primary endpoint, canagliflozin significantly reduced NT-proBNP, compared to glimepiride, in patients with T2D and HF. Our data suggest clinical benefits of SGLT2 inhibitors in that population. Trial Registry Number: This study is registered with the University Medical Information Network Clinical Trial Registry, 000017669. Funding Statement: Mitsubishi Tanabe Pharma Corporation. Declaration of Interests: AT has received modest honoraria from Astellas, AstraZeneca, Boehringer Ingelheim, Daiichi Sankyo, MSD, Mitsubishi Tanabe, Novo Nordisk, Taisho Toyama, and Takeda. IT has received grants and personal fees from Mitsubishi Tanabe, AstraZeneca, Bristol-Myers Squibb, Bayer, Takeda, Daiichi Sankyo, Otsuka, MSD, Shionogi, Kowa, Sumitomo Dainippon, Boehringer Ingelheim, Mitsubishi Tanabe, and Mochida. MS has received grants and personal fees from Mitsubishi Tanabe, Takeda, Daiichi Sankyo, Astellas, Pfizer, Novartis, Boehringer Ingelheim, Bayer, MSD, Kowa, and AstraZeneca. SU has received grants from Kowa, Bristol-Myers Squibb, Bayer, honoraria from MSD, Boehringer Ingelheim, and Chugai. JO belongs to the endowed department of Fukuda Denshi. MK has received grants from Japanese government, Japan Heart Foundation, Japan Cardiovascular Research Foundation, Novartis, Nihon Kohden, and Kureha, grants and personal fees from Astellas, Pfizer, Ono, Mitsubishi Tanabe, and AstraZeneca, personal fees from Daiichi Sankyo. TM has received grants from Mitsubishi Tanabe, and Boehringer Ingelheim, personal fees from Mitsubishi Tanabe, Boehringer Ingelheim, Eli Lilly, AstraZeneca, Ono, and Kowa. KN has received grants from Mitsubishi Tanabe, during the conduct of the study; personal fees from MSD, Astellas, Amgen Astellas, AstraZeneca, Eli Lilly, Otsuka, Daiichi Sankyo, Takeda, Boehringer Ingelheim, Bayer, Pfizer, Ono, and Mitsubishi Tanabe, grants from Asahi Kasei, Astellas, Mitsubishi Tanabe, Teijin, Terumo, Boehringer Ingelheim, and Bayer, scholarship from Bayer, Daiichi Sankyo, Teijin, Astellas, Takeda, and Bristol-Myers Squibb. All other authors declare no competing interests. Ethics Approval Statement: The trial was approved by individual sites’ institutional review boards or independent ethics committees, in compliance with the Declaration of Helsinki and the current legal regulations in Japan.

Experimental ischemia-reperfusion models have shown that 3-hydroxy-3methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, statins, have cardioprotective effects. SAMIT (Statin Acute Myocardial Infarction Trial) is a multicenter prospective open randomized trial, designed to evaluate the effects of statin treatment from the earliest stage on cardioprotection in patients with acute myocardial infarction (AMI). Patients were randomly assigned to receive atorvastatin (initial dose of 40 mg at admission followed by the maintenance dose of 10 mg/day for 30 days) or not (control), and then immediately underwent percutaneous coronary intervention (PCI) for the culprit lesion. The primary endpoints were infarct size and left ventricular function. The secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) and various biomarkers. There were no significant differences in baseline characteristics between 2 groups of the statin treatment group and the control group. The left ventricular ejection fraction increased at 6 months after the onset of AMI, compared with the baseline level in the atorvastatin group (P

AST-120 has been used widely in Japan to slow the deterioration of renal function in patients with chronic kidney disease (CKD) by decreasing uremic toxins. The heart and the kidney are closely related, with cardiorenal interaction being very important. This retrospective study examined whether AST-120 influences the prevalence of dialysis induction, mortality, and cardiac and stroke events in CKD patients. The study included 278 patients diagnosed with chronic renal failure (CKD stage: III-V) in 2006. Of these patients, 128 received AST-120 (6 g/day), while the remaining 150 patients did not. A log-rank test was performed to compare dialysis induction, mortality, and cardiac and stroke events in the two groups. Univariate and multivariate Cox proportional hazard regression analyses were used to identify the potential factors that contributed to dialysis induction, mortality, and cardiac and stroke events over the next 5 years. Patient profiles before the study were almost the same other than age, primary disease (DM or non-DM) and urine volume. The prevalence of dialysis induction, mortality, and cardiac and stroke events in patients treated with AST-120 was significantly lower after 3 and 5 years (p 0.0001) compared with the prevalence observed in the untreated patients. The absence of AST-120 treatment was associated independently with a high risk of dialysis induction (hazard ratio 4.979, 95 % CI 3.502-7.079, p 0.0001), mortality (4.536, 2.666-7.720, p 0.0001), cardiac event (3.590, 2.572-5.011, p 0.001) and stroke (1.949, 1.342-2.829, p = 0.0005). The results of this retrospective analysis suggest that long-term treatment with AST-120 may improve the prognosis of CKD patients in the pre-dialysis stage. Long-term (i.e., 5 years) prospective randomized studies are needed to confirm the findings of the current study.

2-Cl-C.OXT-A (COA-Cl) is a novel nucleic acid analogue that promotes tube-forming activity of human umbilical vein endothelial cells (HUVEC) through vascular endothelial growth factor (VEGF). The development of coronary collateral circulation is critical to rescue the ischemic myocardium and to prevent subsequent irreversible ischemic injury. We evaluated whether COA-Cl can promote angiogenesis in ischemic tissue, reduce infarct size and preserve cardiac contractility in vivo. Mice received COA-Cl or placebo daily for three days after myocardial infarction (MI) by coronary ligation. The degree of angiogenesis in ischemic myocardium was assessed by staining endothelial cells and vascular smooth muscle cells, and measuring infarct size/area-at-risk. In mice treated with COA-Cl, enhanced angiogenesis and smaller infarct size were recognized, even given a similar area at risk. We observed increases in the protein expression levels of VEGF and in the protein phosphorylation level of eNOS. In addition, the heart weight to body weight ratio and myocardial fibrosis in COA-Cl mice were decreased on Day 7. Administration of COA-Cl after MI promotes angiogenesis, which is associated with reduced infarct size and attenuated cardiac remodeling. This may help to prevent heart failure due to cardiac dysfunction after MI.

Low body mass index (BMI) has been associated with decreased survival in patients with heart failure (HF), although Obesity is an important risk factor for cardiovascular disease. HF patients with a relatively higher BMI tend to live longer, which is known as "Obesity Paradox". However, cardiac cachexia is another determinant of prognosis in HF patients. This study investigated whether a change in BMI is associated with either prognosis or frequency of hospitalizations in patients with HF.We correlated changes in BMI to prognosis and frequency of hospitalizations in patients who were hospitalized for decompensated HF. A total of 971 HF patients were initially evaluated, and 81 patients with repeat HF admissions were included.The average change in BMI was -0.05 ± 0.15, -0.87 ± 0.56, -1.03 ± 0.34, and -1.97 ± 0.33 in patients who were hospitalized twice, three times, four times, and over five times, respectively. The reduction in BMI correlated with the frequency of hospitalizations (P 0.01). We compared patients with increased BMI (group I, n = 38) versus decreased BMI (group D, n = 43) between the first and second discharge. The rate of hospitalization in group D was higher than in group I, and group D had a lower survival rate. The reduction of BMI was a significant and independent risk factor for cardiac death (HR, 4.17; 95% CI, 1.53 to 14.6).Losing body weight in HF patients was a significant predictive factor of the frequency of hospitalizations and increased mortality.

Endothelial dysfunction contributes to poor cardiovascular prognosis in patients with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD). The effect of dipeptidyl peptidase-4 inhibitors on endothelial function remains controversial. We sought to compare the effects of linagliptin and voglibose on endothelial function, as assessed by reactive hyperemia-peripheral arterial tonometry (RH-PAT). Sixteen patients with newly diagnosed T2DM and CAD were randomized 1:1 to linagliptin (5 mg, once-daily) or voglibose (0.9 mg, thrice-daily). The RH-PAT and laboratory parameters, including 75 g oral glucose tolerance test, were measured at baseline and 3 months. Linagliptin increased serum levels of active glucagon-like peptide-1 and high-molecular-weight adiponectin. Age-, sex-, and baseline-adjusted changes in logarithmic RH-PAT index (LnRHI) after 3 months were significant between groups (linagliptin, 0.135 ± 0.097; voglibose, - 0.124 ± 0.091; P = 0.047). In the linagliptin group, change in LnRHI was positively correlated with change in high-density lipoprotein cholesterol and negatively correlated with changes in both urine albumin-to-creatinine ratio and high-sensitivity C-reactive protein. Furthermore, linagliptin treatment for 3 months reduced serum levels of both glucose and insulin at 2 h, relative to voglibose, in the age-, sex-, and baseline-adjusted model. Linagliptin improved endothelial function relative to voglibose, accompanied by amelioration of glycemic, renal, and cardiometabolic parameters, in patients with newly diagnosed T2DM and CAD.Trial registration Unique Trial Number, UMIN 000029169 ( https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000012442 ).

The aims of this study were to investigate the impact of caloric restriction (CR) on cardiac telomere biology in an animal model of diabetes and to examine the signal transduction involved in cell senescence as well as cardiac function. Male 8-week-old Otsuka Long-Evans Tokushima fatty (OLETF) diabetic rats were divided into two groups: a group fed ad libitum (OLETF-AL) and a group fed with CR (OLETF-CR: 30 % energy reduction). Long-Evans Tokushima Otsuka (LETO) non-diabetic rats were used as controls. LETO rats were also divided into two groups: a CR (LETO-CR) group and a group fed AL (LETO-AL). At 40 weeks of age, the body weight was decreased by 9.7 % and the insulin resistance was less in OLETF-CR rats. Telomerase activity in OLETF-CR rats was significantly increased, and telomerase reverse transcriptase was more highly expressed in those rats. However, the telomere length (TL) was not different between AL- and CR-treated rats of each strain. The protein expressions for FoxO1 and FoxO3 were increased in OLETF-AL rats, but the levels of phosphorylated (p)-Akt were decreased compared to those in OLETF-CR rats. Autophagic LC3II signals revealed significant increases in OLETF-CR rats. Echocardiography showed that OLETF-CR improved the left ventricular diastolic dysfunction without changes in the left ventricular dimension. This study revealed that CR increases cardiac telomerase activity without TL attrition, and significantly ameliorates diastolic dysfunction. These findings suggest that cardiac telomerase activity may play an important role in the maintenance of normal cardiac function.

Background Type 2 diabetes mellitus (T2DM) is characterized by systemic metabolic abnormalities and the development of micro- and macrovascular complications, resulting in a shortened life expectancy. A recent cardiovascular (CV) safety trial, the EMPA-REG OUTCOME trial, showed that empagliflozin, a sodium glucose cotransporter 2 (SGLT2) inhibitor, markedly reduced CV death and all-cause mortality and hospitalization for heart failure in patients with T2DM and established CV disease (CVD). SGLT2 inhibitors are known to not only decrease plasma glucose levels, but also favorably modulate a wide range of metabolic and hemodynamic disorders related to CV pathways. Although some experimental studies revealed a beneficial effect of SGLT2 inhibitors on atherosclerosis, there is a paucity of clinical data showing that they can slow the progression of atherosclerosis in patients with T2DM. Therefore, the EMBLEM trial was designed to investigate whether empagliflozin treatment can improve endothelial function, which plays a pivotal role in the pathogenesis of atherosclerosis, in patients with T2DM and established CVD. Methods The EMBLEM trial is an ongoing, prospective, multicenter, placebo-controlled double-blind randomized, investigator-initiated clinical trial in Japan. A total of 110 participants with T2DM (HbA1c range 6.0–10.0%) and with established CVD will be randomized (1:1) to receive either empagliflozin 10 mg once daily or a placebo. The primary endpoint of the trial is change in the reactive hyperemia (RH)-peripheral arterial tonometry-derived RH index at 24 weeks from baseline. For comparison of treatment effects between the treatment groups, the baseline-adjusted means and their 95% confidence intervals will be estimated by analysis of covariance adjusted for the following allocation factors: HbA1c ( Discussion EMBLEM is the first trial to assess the effect of empagliflozin on endothelial function in patients with T2DM and established CVD. Additionally, mechanisms associating empagliflozin-mediated actions with endothelial function and other CV markers will be evaluated. Thus, the trial is designed to elucidate potential mechanisms by which empagliflozin protects CV systems and improves CV outcomes. Trial registration Unique Trial Number, UMIN000024502 (https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000028197)

Type 2 diabetes mellitus (T2DM) is widely prevalent and a critical risk factor for cardiovascular disease that increases both morbidity and mortality. Recently, new therapies based on the actions of the incretin hormones have become widely used, offering advantages over conventional treatments by limiting hypoglycemia and achieving glycemic control. Moreover, many experimental studies have suggested that GLP-1 and related drugs exert cardioprotective effects on atherosclerosis and cardiac dysfunction both in vitro and in vivo. However, there is thus far little clinical evidence supporting the efficacy of incretin therapy in patients with cardiovascular disease. This review focuses on the effects of GLP-1-related therapy on cardiac function from the bench to the bed, with a discussion of possible underlying mechanisms.

Background Experimental studies have suggested that dipeptidyl peptidase-4 (DPP-4) inhibitors provide cardiovascular protective effects. We performed a randomized study to evaluate the effects of sitagliptin added on to the conventional therapy compared with conventional therapy alone (diet, exercise, and/or drugs, except for incretin-related agents) on the intima-media thickness (IMT) of the carotid artery, a surrogate marker for the evaluation of atherosclerotic cardiovascular disease, in people with type 2 diabetes mellitus (T2DM). Methods and Findings We used a multicenter PROBE (prospective, randomized, open label, blinded endpoint) design. Individuals aged ≥30 y with T2DM (6.2% ≤ HbA1c < 9.4%) were randomly allocated to receive either sitagliptin (25 to 100 mg/d) or conventional therapy. Carotid ultrasound was performed at participating medical centers, and all parameters were measured in a core laboratory. Of the 463 enrolled participants with T2DM, 442 were included in the primary analysis (sitagliptin group, 222; conventional therapy group, 220). Estimated mean (± standard error) common carotid artery IMT at 24 mo of follow-up in the sitagliptin and conventional therapy groups was 0.827 ± 0.007 mm and 0.837 ± 0.007 mm, respectively, with a mean difference of −0.009 mm (97.2% CI −0.028 to 0.011, p = 0.309). HbA1c level at 24 mo was significantly lower with sitagliptin than with conventional therapy (6.56% ± 0.05% versus 6.72% ± 0.05%, p = 0.008; group mean difference −0.159, 95% CI −0.278 to −0.041). Episodes of serious hypoglycemia were recorded only in the conventional therapy group, and the rate of other adverse events was not different between the two groups. As it was not a placebo-controlled trial and carotid IMT was measured as a surrogate marker of atherosclerosis, there were some limitations of interpretation. Conclusions In the PROLOGUE study, there was no evidence that treatment with sitagliptin had an additional effect on the progression of carotid IMT in participants with T2DM beyond that achieved with conventional treatment. Trial Registration University Hospital Medical Information Network Clinical Trials Registry UMIN000004490, In a randomized controlled trial, Koichi Node and colleagues assess the efficacy of sitagliptin in limiting atherosclerosis among patients over 29 years of age living in Japan., Author Summary Why Was This Study Done? Translational research suggests that dipeptidyl peptidase-4 (DPP-4) inhibitors, which are drugs for type 2 diabetes mellitus (T2DM), may prevent cardiovascular disease to a greater extent than other T2DM drugs. However, recently published large clinical trials showed no additional efficacy for DPP-4 inhibitors beyond that expected for the drugs’ glycemic control. Possibly these studies showed no benefit to cardiovascular health because they assessed cardiovascular mortality and other relatively rare outcomes. Change in carotid intima-media thickness (IMT) is a simple, noninvasive method to assess atherosclerosis, an intermediate and more common condition that can precede cardiovascular disease. What Did the Researchers Do and Find? We conducted a trial to evaluate whether DPP-4 inhibitors affect atherosclerosis in people with T2DM. In all, 463 participants recruited at 48 medical centers were randomly divided into two groups and treated with sitagliptin, a DPP-4 inhibitor, or other conventional drugs for two years. Carotid IMT was evaluated with ultrasonography in a blinded manner. We found that annual changes in carotid IMT were not significantly different between the two groups. On the other hand, the decrease in HbA1c and in the incidence of hypoglycemia with sitagliptin were superior to conventional therapy. The rate of other adverse events was not different between the two groups. What Do These Findings Mean? These findings provide no evidence that sitagliptin slows the progression of carotid intima-media thickening in participants with T2DM to a greater extent than conventional drugs. As some of the conventional anti-T2DM drugs have shown anti-atherosclerotic effects in clinical trials, the present findings do not mean that sitagliptin does not possess anti-atherosclerotic properties in participants with T2DM. Importantly, however, sitagliptin is useful for controlling hyperglycemia for clinical setting.

Background Because type 2 diabetes mellitus is associated strongly with an increased risk of cardiovascular diseases, the number of patients with diabetes with chronic heart failure is increasing steadily. However, clinical evidence of therapeutic strategies in such patients is still lacking. A recent randomized, placebo-controlled trial in patients with type 2 diabetes with high cardiovascular risk demonstrated that the SGLT2 inhibitor, empagliflozin, reduced the incidence of hospitalization for heart failure. Because SGLT2 inhibitors cause a reduction in body weight and blood pressure in addition to improving glycemic control, they have the potential to exert beneficial effects on the clinical pathophysiology of heart failure. The aim of the ongoing CANDLE trial is to test the safety and non-inferiority of canagliflozin, another SGLT2 inhibitor, compared with glimepiride, a sulfonylurea agent, in patients with type 2 diabetes mellitus and chronic heart failure. Methods A total of 250 patients with type 2 diabetes who are drug-naïve or taking any anti-diabetic agents and suffering from chronic heart failure with a New York Heart Association classification I to III will be randomized centrally into either canagliflozin or glimepiride groups (1: 1) using the dynamic allocation method stratified by age (

Background An excessive inflammatory response after myocardial infarction (MI) increases myocardial injury. The toll‐like receptor (TLR)‐4 is activated by the recognition of endogenous ligands and is proinflammatory when there is myocardial tissue injury. The apoptosis inhibitor of the macrophage (AIM) is known to provoke an efflux of saturated free fatty acids (FFA) due to lipolysis, which causes inflammation via the TLR‐4 pathway. Therefore, this study investigated the hypothesis that AIM causes a proinflammatory response after MI. Methods and Results The left anterior descending coronary artery was ligated to induce MI in both AIM‐knockout (AIM −/− ) and wild‐type (WT) mice. After 3 days, the inflammatory response from activation of the TLR‐4/NFκB pathway was assessed, and infarct size was measured by staining with triphenyltetrazolium chloride. In addition, left ventricular remodeling was examined after 28 days. Although the area at risk was similar between AIM −/− and WT mice, the infarct size was significantly smaller in AIM −/− mice ( P =0.02). The heart weight–to–body weight ratio and myocardial fibrosis were also decreased in the AIM −/− mice, and the 28‐day survival rate was improved ( P −/− mice, myocardial IRAK4 and NFκB activity were decreased (all P P P =0.03, respectively). Furthermore, NFκB DNA‐binding activation via TLR‐4, neutrophil infiltration, and inflammatory mediators were decreased in AIM −/− mice. Conclusions The deletion of AIM reduced the inflammatory response and infarct size and improved survival after myocardial infarction.

Background Manganese superoxide dismutase (MnSOD) is an important antioxidant enzyme affected in heart/muscle-specific MnSOD-deficient mice (H/M-SOD2 −/− ), which develop progressive congestive heart failure and exhibit pathology typical of dilated cardiomyopathy. Methods In this study we investigated the beneficial effects of epigallocatechin gallate (EGCG) on the cardiac remodeling and telomere biology in H/M-SOD2 −/− mice. H/M-SOD2 −/− mice were divided into three groups: those receiving normal drinking water (KO), a low dose of EGCG (L: 10 mg/L), and a high dose of EGCG (H: 100 mg/L) beginning at eight weeks of age and lasting for eight weeks. Results The mice in the KO group exhibited significantly dilated cardiac remodeling with reduced contractility, which was prevented by the administration of EGCG. Although the mortality of KO mice was about 50% at 16 weeks of age, the mice that received EGCG had a high survival rate. The cardiac dilatation with reduced cardiac contraction in KO mice was prevented by EGCG treatment. The levels of myocardial oxidative stress and free fatty acids were lower in the group treated with EGCG compared with the KO group. The increased expression of nitric oxide synthase 2, nitrotyrosine, fatty acid synthase, Toll-like receptor 4, and Sirt1 in the KO mice were prevented by EGCG treatment. The shortening of the telomere length, decreased telomerase activity in KO mice were also prevented by EGCG. Conclusions H/M-SOD2 −/− mice receiving EGCG have a lower mortality rate and exhibit less inflammation and a better preserved cardiac function and telomere biology.

Balneotherapy has been shown to reduce systemic blood pressure in healthy volunteers. Hyperthermia might ameliorate the inflammatory status in heart failure through improving cardiac function. The purpose of this study was to examine the beneficial effects of balneotherapy in patients with chronic heart failure (CHF). Thirty-two patients with systolic CHF classified as New York Heart Association functional status II or III were randomized to divide either a balneotherapy group or a control group. The patients in the balneotherapy group were immersed in a hot spring at 40°C for 10 min daily for 2 weeks; the control group patients took a shower daily. The left ventricular ejection fraction (EF) and cardiothoracic ratio (CTR) were evaluated and plasma brain natriuretic peptide (BNP), high-sensitivity C-reactive protein (hsCRP), tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6 levels were measured. The clinical symptoms improved after 2 weeks of hot spring therapy. Although the heart rate did not change, clinical symptoms, CTR, EF, and BNP were significantly improved. Moreover, the inflammatory responses, including hsCRP, TNF-α and IL-6 decreased significantly after balneotherapy. The improvement of BNP correlates with the changes in inflammatory biomarkers. Repeated hyperthermia by bathing in a hot spring is therefore considered to improve the cardiac and inflammatory status in patients with CHF.

Oxidative stress plays a pathological role in the development of heart failure. This study examined telomere biology in heart/muscle-specific manganese superoxide dismutase-deficient mice (H/M-SOD2^), which develop progressive congestive heart failure and exhibit pathology typical of dilated cardiomyopathy. EUK-8 (25 mg/kg/day), a superoxide dismutase and catalase mimetic, was administered to H/M-SOD2^ mice for four weeks beginning at 8 weeks of age. Telomere length, telomerase activity, telomere-associated proteins, and cell death signals were assessed in hearts from control wild-type mice (H/M-Sod2^) and H/M-SOD2^ mice either treated or untreated with EUK-8. While cardiac function was unchanged in these experimental mice, the end-diastolic dimension in H/M-SOD2^ mice was notably dilated and could be significantly reduced by EUK-8 treatment. At the end of the study, no shortening of telomere length was observed in heart tissues from all mice tested, but telomerase activity was decreased in heart tissue from H/M-SOD2^ mice compared to control mice. Protein expression for telomerase reverse transcriptase and telomere repeat binding factor 2 was also downregulated in H/M-SOD2^ heart tissue as was expression of phospho-Akt, insulin-like growth factor, and endothelial nitric oxide synthase. Expression levels of Sirt1, a lifespan modulator, were enhanced while FoxO3a was depressed in H/M-SOD2^ hearts. All of the changes seen in H/M-SOD2^ heart tissue could be inhibited by EUK-8 treatment. Taken together, the results suggest that oxidant stress might affect myocardial telomerase activity and telomere-associated proteins. Telomerase may therefore play a pivotal role in antioxidant defense mechanisms, and may be useful as a novel therapeutic tool for treating human heart failure.2010 Elsevier Ltd.

The telomere length and subtelomeric methylated status of peripheral blood leukocytes has been reported to be correlated with many kinds of pathophysiological conditions. However, the correlation between the telomeric parameters and clinical laboratory data in metabolic disorders is not well known. This study investigated the correlation between the telomere length and subtelomeric methylated status in peripheral leukocytes and the laboratory data of male outpatients with combined metabolic disorders and no clinical history of cardiovascular or cerebrovascular event were assessed, to find good clinical laboratory markers reflecting the biological aging. The laboratory data were collected in 26 Japanese male outpatients with diabetes mellitus and hyperlipidemia, and no history of cardiovascular or cerebrovascular event, and the telomeric parameters in their peripheral leukocytes were determined by Southern blot with methylation-sensitive and insensitive isoschizomers. Any correlations between the laboratory data and the telomeric parameters were assessed. The patients showed a significant negative correlation among the bilirubin and creatine phosphokinase with the aging-associate change of the telomeric and subtelomeric parameters. Lowered serum bilirubin and creatinine phosphokinase level correlated to genomic aging represented by telomere attrition of patients with metabolic disorders.

Background: The telomere length and subtelomeric methylated status of peripheral blood leukocytes have been reported to be correlated with many kinds of pathophysiological conditions. However, the correlation between the telomeric parameters and patients’ physical ability is not known. Objective: This study aims to study how telomeric parameters, including telomere length and the subtelomeric methylation status of peripheral blood leukocytes, are associated with the physical inability of patients with cerebrovascular disease and its improvement by inpatient rehabilitation. Methods: The physical ability of female patients with cerebrovascular disease admitted in the chronic disease ward of Kyushu University Hospital was assessed using the Barthel index, and the telomeric parameters in their peripheral blood leukocytes were determined by Southern blotting with methylation-sensitive and -insensitive isoschizomers. Results: The patients revealed a significant correlation between Barthel score and the mean telomere length and expression of long telomeres (>9.4 kb). Improvement of the Barthel index of patients during admission was correlated not to telomere length, but to subtelomeric hypermethylation of long telomeres. Conclusions: The physical ability of patients was positively correlated with the lengths of their somatic telomeres, and the recovery potential of physical ability was associated with the subtelomeric hypermethylated status stabilizing long telomeric structure.

Background: Because green tea reduces cardiovascular and cerebrovascular risk, the purpose of this study aimed to elucidate the effect of green tea catechins (GTC) on endothelial dysfunction in smokers. Methods and Results: The 30 healthy male smokers were divided into 3 groups and given green tea beverages containing 0 mg (control group), 80 mg (medium-dose group) or 580 mg (high-dose group) of GTC daily for 2 weeks. Endothelial-dependent and- independent vasodilatation was investigated by measuring the forearm blood flow (FBF) responses to acetylcholine and sodium nitroprusside using venous occlusion strain-gauge plethysmography. The FBF response to acetylcholine significantly increased at 2 h and 1 and 2 weeks after GTC intake in the high-dose group, but no increase was observed in the other groups. FBF responses to sodium nitroprusside did not alter in any group at any time point. A significant increase in plasma nitric oxide and a decrease in asymmetrical dimethylarginine, malondealdehyde and 4-hydroxynonenal, C-reactive protein, monocyte chemotactic protein-1, and soluble CD40 ligand levels were detected after chronic consumption of high-dose GTC. Conclusions: GTC have antiatherosclerotic effects on dysfunctional vessels in smokers through increasing the level of nitric oxide and reducing oxidative stress. (Circ J 2010; 74: 578 - 588)

Fatty acids stimulate lipid accumulation in parallel with increased expression of adipose differentiation-related protein (ADRP) in liver cells. Although it is generally considered that the fatty acid effect on ADRP expression is mediated by peroxisome proliferator-activated receptors (PPARs), we identified here an additional molecular mechanism using the NMuLi mouse liver nonparenchymal cell line, which expresses PPARgamma and delta but not alpha. Oleic acid (OA) and specific ligands for PPARgamma and -delta stimulated ADRP expression as well as the -2,090-bp ADRP promoter activity which encompasses the PPAR response element (PPRE) adjacent to an Ets/activator protein (AP)-1 site. When the AP-1 site was mutated, OA failed to stimulate the activity despite the presence of the PPRE, whereas ligands for PPARgamma and -delta did stimulate it and so did a PPARalpha ligand under the coexpression of PPARalpha. DNA binding of AP-1 was stimulated by OA but not by PPAR ligands. Because we previously demonstrated that Pycnogenol (PYC), a French maritime pine bark extract, suppressed ADRP expression in macrophages partly by suppression of AP-1 activity, we tested the effect of PYC on NMuLi cells. PYC reduced the OA-induced ADRP expression along with suppression of lipid droplet formation. However, PYC neither suppressed the OA-stimulated ADRP promoter activity nor DNA binding of AP-1 but, instead, reduced the ADRP mRNA half-life. All these results indicate that the effect of OA on ADRP expression requires AP-1 as well as PPRE, and PYC suppresses the ADRP expression in part by facilitating mRNA degradation. PYC, a widely used dietary supplement, could be beneficial for the prevention of excessive lipid accumulation such as hepatic steatosis.

Background Diagonal earlobe crease (ELC) have been proposed as a marker of generalized atherosclerosis, so in the present study it was investigated whether individuals with ELC have a shortened telomere, which correlates with an accelerated cell turnover and premature aging, leading to atherosclerosis. Methods and Results The mean terminal restriction fragment (TRF) was determined by Southern blot hybridization in the peripheral blood cells of 34 male Japanese patients with metabolic syndrome (MetS) who were under 70 years of age with (n=17) and without (n=17) bilateral ELC, and assessed the relationship of ELC to atherosclerotic cardiovascular disease (AVD). The results showed that the TRF was shorter in the MetS patients with ELC in comparison to age- and risk-factor-matched MetS patients without ELC (7.6±1.1 kbp vs 8.6±1.2 kbp; P

Telomeres are the repeated sequences at the chromosome ends which undergo shortening with cell division. The telomere shortening of the peripheral leukocytes is also facilitated by enhanced oxidative stress in various kinds of disease including ischemic heart disease, diabetes mellitus, apoplexy, and Alzheimer's disease. Telomere shortening in Parkinson's disease (PD) has not yet been reported. The pathogenesis for PD is also regarded to be associated with oxidative stress. We investigated 28 Japanese male PD patients ages 47-69. Although we could not find a statistical difference in the mean telomere length of peripheral leukocytes between the PD patients and the control participants, we found the mean telomere lengths to be shorter than 5 kb in only the PD patients and a significant PD-associated decrease in the telomeres with a length ranging from 23.1 to 9.4 kb in the patients in their 50s and 60s. These observations suggest that telomere shortening is accelerated in PD patients in comparison to the normal population.

Background Small caliber vascular prostheses are not clinically available because synthetic vascular prostheses lack endothelial cells which modulate platelet activation, leukocyte adhesion, thrombosis, and the regulation of vasomotor tone by the production of vasoactive substances. We developed a novel method to create scaffold-free tubular tissue from multicellular spheroids (MCS) using a “Bio-3D printer”-based system. This system enables the creation of pre-designed three-dimensional structures using a computer controlled robotics system. With this system, we created a tubular structure and studied its biological features. Methods and Results Using a “Bio-3D printer,” we made scaffold-free tubular tissues (inner diameter of 1.5 mm) from a total of 500 MCSs (2.5× 104 cells per one MCS) composed of human umbilical vein endothelial cells (40%), human aortic smooth muscle cells (10%), and normal human dermal fibroblasts (50%). The tubular tissues were cultured in a perfusion system and implanted into the abdominal aortas of F344 nude rats. We assessed the flow by ultrasonography and performed histological examinations on the second (n = 5) and fifth (n = 5) day after implantation. All grafts were patent and remodeling of the tubular tissues (enlargement of the lumen area and thinning of the wall) was observed. A layer of endothelial cells was confirmed five days after implantation. Conclusions The scaffold-free tubular tissues made of MCS using a Bio-3D printer underwent remodeling and endothelialization. Further studies are warranted to elucidate the underlying mechanism of endothelialization and its function, as well as the long-term results.

Background Obstructive sleep apnea (OSA) is characterized by repetitive intermittent hypoxia and reoxygenation during sleep with elevated oxidative stress and promotes the development of atherosclerosis, as demonstrated by vascular dysfunction and chronic inflammation. An increased neutrophil to lymphocyte ratio (NLR) has been recognized to be a novel inflammatory biomarker for systemic inflammation. Objectives We evaluated whether the NLR reflects the severity of OSA and if continuous positive airway pressure (CPAP) treatment ameliorates the endothelial function and NLR in patients with OSA. Methods We enrolled 95 patients with suspected OSA and 29 patients who received CPAP therapy for 3 months. We evaluated the number of endothelial progenitor cells (EPCs) and NLR, the levels of nitric oxide (NOx) and asymmetric dimethylarginine (ADMA), and the endothelial function according to the flow-mediated dilatation (FMD) before and after CPAP treatment. Results The levels of apnea–hypopnea index demonstrated an inverse relationship with the FMD and a positive relationship with the NLR. Moreover, NLR is an independent factor suggested for the presence of severe OSA. CPAP therapy increased the levels of EPC and NOx and decreased the level of ADMA. CPAP treatment also improved the FMD and decreased the NLR. Conclusions NLR and endothelial dysfunction significantly correlates with the severity of OSA and FMD and other biochemical parameters improved and NLR decreased significantly after CPAP treatment.

Background The aim of our study was to develop a completely scaffold-free, viable, contractile cardiac tissue capable of being grafted into the damaged native heart. Methods Our technology is based on the fundamental characteristics of the self-assembling nature of cells. We created contractile cardiac spheroids by plating a mixture of rat neonatal ventricular cardiomyocytes, human dermal fibroblasts, and human coronary microartery endothelial cells in ultralow attachment plates. First, the optimal cell ratios for the 3 cell sources were determined. Next, approximately 1 × 10 4 optimal spheroids were fused into a patch-like construct, and the morphologic characteristics and mechanical functions of these patches were evaluated. Finally, the cardiac patches were grafted into the hearts of F344 nude rats, and histologic studies were performed after transplantation. Results Synchronous beating of the cardiac patch was confirmed electrophysiologically and mechanically. A micronetwork of endothelial cells was also demonstrated in the construct, and the histologic study performed 5 days after transplantation showed the grafts to be viable, with functioning microvascular structures inside the graft tissue. Conclusions We consider the application of our scaffold-free 3-dimensional tissue engineering technology to cardiac regeneration therapy is feasible and expect that this technology will become a promising tool for the treatment of end-stage heart failure.

A 76-year-old immunocompetent woman presented to our hospital with general fatigue. Her blood pressure was 60/40 mm Hg and pulse rate was 110 bpm. An electrocardiogram showed ST-elevation in the II, III and aVF leads with complete atrioventricular block. An echocardiogram and CT revealed pericardial effusion and a 6 cm solid tumour lying anterior to the heart. The right coronary artery (RCA) ran through the centre of the tumour, which bulged into the right atrium for 35 mm and vibrated. Emergent coronary angiography revealed 99% stenosis with delay at the proximal RCA; however, intravascular ultrasound showed no atheromatous changes, and the RCA was compressed by the extravascular mass. Successful coronary stenting improved the coronary flow. The following day, a biopsy was performed via thoracotomy without any events, the results of which showed diffuse-type large B-cell lymphoma histologically. Chemotherapy gradually reduced the tumour size, and the patient became stable haemodynamically.

Background—Myocardial ischemia and reperfusion-induced tissue injury involve a robust inflammatory response, but the proximal events in reperfusion injury remain incompletely defined. Toll-like receptor 4 (TLR4) is a proximal signaling receptor in innate immune responses to lipopolysaccharide of Gram-negative pathogens. TLR4 is also expressed in the heart and vasculature, but a role for TLR4 in the myocardial response to injury separate from microbial pathogens has not been examined. This study assessed the role of TLR4 in myocardial infarction and inflammation in a murine model of ischemia-reperfusion injury.Methods and Results—Myocardial ischemia-reperfusion (MIR) was performed on 2 strains of TLR4-deficient mice (C57/BL10 ScCr and C3H/HeJ) and controls (C57/BL10 ScSn and C3H/OuJ). Mice were subjected to 1 hour of coronary ligation, followed by 24 hours of reperfusion. TLR4-deficient mice sustained significantly smaller infarctions compared with control mice given similar areas at risk. Fewer neutrophils infiltrated the myocardium of TLR4-deficient Cr mice after MIR, indicated by less myeloperoxidase activity and fewer CD45/GR1-positive cells. The myocardium of TLR4-deficient Cr mice contained fewer lipid peroxides and less complement deposition compared with control mice after MIR. Serum levels of interleukin-12, interferon-γ, and endotoxin were not increased after ischemia-reperfusion. Neutrophil trafficking in the peritoneum was similar in all strains after injection of thioglycollate.Conclusions—TLR4-deficient mice sustain smaller infarctions and exhibit less inflammation after myocardial ischemia-reperfusion injury. The data suggest that in addition to its role in innate immune responses, TLR4 serves a proinflammatory role in murine myocardial ischemia-reperfusion injury.

Background — Ischemia and oxidative stress are the leading mechanisms for tissue injury. An ideal strategy for preventive/protective therapy would be to develop an approach that could confer long-term transgene expression and, consequently, tissue protection from repeated ischemia/reperfusion injury with a single administration of a therapeutic gene. In the present study, we used recombinant adeno-associated virus (rAAV) as a vector for direct delivery of the cytoprotective gene heme oxygenase-1 (HO-1) into the rat myocardium, with the purpose of evaluating this strategy as a therapeutic approach for long-term protection from ischemia-induced myocardial injury. Methods and Results — Human HO-1 gene (hHO-1) was delivered to normal rat hearts by intramyocardial injection. AAV-mediated transfer of the hHO-1 gene 8 weeks before acute coronary artery ligation and release led to a dramatic reduction (>75%) in left ventricular myocardial infarction. The reduction in infarct size was accompanied by decreases in myocardial lipid peroxidation and in proapoptotic Bax and proinflammatory interleukin-1β protein abundance, concomitant with an increase in antiapoptotic Bcl-2 protein level. This suggested that the transgene exerts its cardioprotective effects in part by reducing oxidative stress and associated inflammation and apoptotic cell death. Conclusions — This study documents the beneficial therapeutic effect of rAAV-mediated transfer, before myocardial injury, of a cytoprotective gene that confers long-term myocardial protection from ischemia/reperfusion injury. Our data suggest that this novel “pre-event” gene transfer approach may provide sustained tissue protection from future repeated episodes of injury and may be beneficial as preventive therapy for patients with or at risk of developing coronary ischemic events.

Strong evidence links cardiomyocyte loss to the pathology of some forms of heart failure. Both necrotic and apoptotic modes of cell death have been invoked as the mechanism underlying progressive cardiomyocyte dropout. Nitric oxide (NO) has received particular attention as a candidate reactive oxygen intermediate that influences not only cardiac function, but also cell death elicited by both apoptotic and necrotic mechanisms. NO is produced by resident cardiac cells under stress, and is produced in large quantities by activated immune cells that infiltrate the injured heart. A review of the literature, however, reveals that the actions of NO on apoptotic cell death are complex, especially in the context of heart disease, and that the practical contribution of NO to cell death in heart disease is yet to be defined.

Background The purpose of this study was to elucidate the effects of glimepiride on the levels of biomarkers related to cardiovascular regulation in patients with type 2 diabetes mellitus. Methods and results Thirty-four patients with type 2 diabetes received glimepiride for 24 weeks. Significant decreases in the levels of glyceraldehyde-derived advanced glycation end products, (glycer-AGE: toxic AGE), eotaxin and fibroblast growth factor (FGF)-2 were recognized after the administration of glimepiride. Moreover, there were trends for there to be increases in the levels of granulocyte-colony stimulating factor (G-CSF) and granulocyte macrophage-colony stimulating factor (GM-CSF), and decreases in the levels of fractalkine, soluble CD40 ligand (sCD40L), macrophage inflammatory protein (MIP)-β, vascular endothelial growth factor (VEGF) and soluble receptor for AGE (sRAGE). Conclusions Glimepiride may have potent anti-oxidative, anti-inflammatory and angiogenic properties and it may potentially repair tissue damage by decreasing the levels of toxic AGE and increasing colony-stimulating factors.

BACKGROUND Inflammatory cytokines may play an important role in the pathogenesis of atherosclerosis and heart failure. We have previously demonstrated that long-term treatment with interleukin (IL)-1beta in the coronary artery and myocardium promotes coronary arteriosclerosis and impairs cardiac function, respectively. The cytokines in pericardial fluid may reflect the extent of coronary atherosclerosis and may also directly promote the atherosclerotic process. This study was designed to examine the significance of cytokine concentrations in pericardial fluid of patients with cardiovascular disease. METHODS We measured concentrations of 10 major cytokines in the pericardial fluid of 56 consecutive patients obtained during open heart surgery, 27 with ischemic heart disease (IHD group), 21 with valvular heart disease (VHD group) and eight with congenital heart disease (CHD group). RESULTS The pericardial concentrations of IL-1beta (pg/ml) were significantly higher in the IHD group (60 +/- 15) than in the VHD (29 +/- 5) or the CHD group (26 +/- 4) (P < 0.05 both). There was no significant difference in pericardial concentrations of other cytokines among the three groups. In the IHD group, the IL-1beta concentrations were significantly elevated in patients who had undergone emergency operations or in those with unstable angina. CONCLUSIONS These results suggest that pericardial concentrations of IL-1beta may reflect the extent of ischemic heart disease and that elevated IL-1beta concentrations in pericardial fluid may also directly promote the process of coronary atherosclerosis.

Adhesion molecules are key molecules for inflammatory cardiovascular diseases and are known to be up-regulated by inflammatory cytokines. However, the role of adhesion molecules in the cytokine-induced myocardial dysfunction in vivo remains unclear. This role was examined in our novel canine model, in which chronic treatment of the heart with IL-1 beta-bound microspheres (MS), but not control MS, causes sustained myocardial dysfunction in vivo. The expression of P-selectin (mRNA and immunoreactivity) was more prominent in the IL-1 beta group than in the control group (treated with control MS alone) after MS injection. The extent of neutrophil infiltration and myocardial myeloperoxidase (MPO) activity were significantly increased in the IL-1 beta group (P0.01). Pre-treatment with SLeX-OS (a novel oligosaccharide analog of sialyl LewisX) or PB1.3 (a monoclonal antibody to P-selectin) prevented the myocardial dysfunction and significantly suppressed the neutrophil infiltration and the increase in myocardial MPO activity induced by IL-1 beta (P0.01 each). These results indicate that adhesion molecules play an important role in the pathogenesis of the cytokine-induced sustained myocardial dysfunction in dogs in vivo.

To determine whether L-arginine, a precursor of nitric oxide, can improve exercise-induced vasodilation of the forearm in patients with heart failure, we measured forearm blood flow in 9 patients with heart failure and in 7 age-matched control subjects before and after intra-arterial infusion of L-arginine. Resting forearm blood flow was significantly lower in patients with heart failure than in control subjects (2.34 +/- 0.85 (SD) vs 4.76 +/- 0.77 ml/min per 100 ml, p < 0.001). Endothelium-dependent vasodilation induced by acetylcholine was attenuated in patients with heart failure (p < 0.05). Exercise-induced vasodilation after handgrip exercise was significantly lower in patients with heart failure (p < 0.05). Intra-arterial infusion of L-arginine did not change basal forearm blood flow but significantly augmented acetylcholine-induced vasodilation in both patients with heart failure and control subjects (p < 0.05). Although L-arginine did not affect maximum forearm blood flow after handgrip exercise in control subjects (before, 26.2 +/- 13.5; after, 25.7 +/- 14.3; p = NS), it was increased in patients with heart failure (from 15.2 +/- 4.9 to 24.7 +/- 14.6, p < 0.01). The finding that L-arginine increased both acetylcholine- and exercise-induced vasodilation in patients with heart failure suggests that endothelial dysfunction might play an important role in impaired exercise-induced vasodilation in patients with heart failure.

Background Recently, incretin hormones, including glucagon-like peptide-1 (GLP-1) analogue and dipeptidyl peptidase-4 (DPP-4) inhibitor, have been found to regulate glucose metabolism. The aim of this study was to elucidate the efficacy and safety of the clinical usage of DPP-4 inhibitors in Japan. Methods This study was designed as a prospective, open-label, multi-center trial. Patients with diabetes mellitus type 2 (T2DM) with poor glycemic profiles (HbA1c ≥ 6.2%) in spite of receiving a medical diet, therapeutic exercise, and/or medications were eligible for this study. The participants received 50 to 100 mg of the DPP-4 inhibitor sitagliptin once daily for 12 months. Results One hundred and eighty-eight subjects were enrolled. After 12 months of sitagliptin treatment, HbA1c levels decreased (7.65% ± 1.32% to 7.05% ± 1.10%, p Conclusions These results suggest that the actions of DPP-4 inhibitors improve not only glycemic control, but also blood pressure, lipid profiles, and quality of life (QOL). Sitagliptin is a sound agent for use in the comprehensive treatment of patients with T2DM.