Dissertationen zum Thema „Heart Metabolism“

Treatments aimed at modifying cardiac substrate utilisation are designed to improve metabolic efficiency. In the fasting state, the heart mainly relies on fatty acid oxidation for its energy production. The heart can adapt to metabolise glucose, lactate and amino acids depending on the predominate milieu and demands placed upon it. A shift from fatty acid oxidation to carbohydrate oxidation leads to a lower oxygen consumption per unit of adenosine triphosphate produced. It is this concept of improving cardiac efficiency by a reduction in oxygen demand that underpins the use of metabolic manipulating agents as a therapeutic strategy in heart failure. Cardiac energy starvation is increasingly recognised as playing a central role in the pathophysiology of heart failure. Alterations in substrate utilisation thus underlie the hope that metabolic manipulating agents will be of benefit in heart failure of both ischaemic and non-ischaemic origin. This metabolic shift is achieved by promoting glucose utilisation and reducing the utilisation of fatty acids. This leads to a greater production of adenosine triphosphate per unit of oxygen consumed. With an ongoing demand for treatment options in ischaemic heart disease and the growing burden of chronic heart failure, new treatment modalities beyond contemporary therapy warrant consideration. This thesis aims to investigate the short term effects of metabolic manipulation on changes in cardiac energetic status, cardiac function, efficiency and substrate utilisation.

Chronic ventricular sympathectomy elicits changes in the coronary circulation, myocardial oxygen consumption and size of infarction resulting fromcoronary occlusion. These changes indicate a change occurring in the basic metabolism of the heart in response to the removal of its sympathetic nervous input. This hypothesis was tested using two groups of dogs, a shamoperated control and a ventricular sympathectomized group. The sympathectomy procedure was an intrapericardial surgical technique which selectively removes ventricular sympathetic input. Four weeks after surgery, left ventricular tissue samples were obtained and rapidly frozen to -80°C. Selected metabolic variables were then compared between the two groups.

This study is based on a proposal concerning the feasibility of using aliphatic tertiary amine N-oxides as antiarrhythmic agent prodrugs. Lignocaine was selected as a candidate for prodrug development, because the N-oxide is a non-active, polar derivative of lignocaine and the drug of choice for ventricular arrhythmia, a symptom associated with ischaemic episodes leading to regions of transiently hypoxic heart tissue. An HPLC analytical method was developed to study the metabolism of lignocaine N-oxide. The rapid and sensitive analysis of lignocaine and its metabolites was demonstrated with good reproducibility, stability and high recovery. In this study, it was identified that lignocaine N-oxide can be reduced to its active parent compound, lignocaine with no other metabolites detected in the absence of oxygen. Under anaerobic conditions, no further metabolism of lignocaine was demonstrated in rat liver microsomes and heart S9 fractions suggesting no secondary metabolites were formed. The reduction of lignocaine N-oxide has been shown to be both enzymic and non-enzymic, NADPH dependent, oxygen sensitive and can be suppressed by CO, CN- and protein denaturation. Under anaerobic conditions, in vitro lignocaine N-oxide reduction was found to occur in NADPH supplemented rat liver homogenates, microsomal suspensions; rat heart homogenates, cytosolic solutions; human phenotyped cytochrome P450 isoforms; purified enzymes- cytochrome P450 reductase, xanthine oxidase, deoxymyoglobin and NADPHI ascorbate reduced protohaem (haemin). This reaction can be suppressed through the chemically mediated decrease ofP450 and bs levels in rat liver microsomes. Previous studies demonstrated that lignocaine N-oxide was non-active in aerobic rat heart in vivo and was potent under ischaemic conditions. In this study, high recovery of lignocaine N-oxide was found in the urine of normal rats suggesting low metabolism of the prodrug in oxic tissues. However, in hypoxic isolated rat hearts, lignocaine N-oxide was found to be reduced to lignocaine. The data presented suggested that the bioactivation of lignocaine N-oxide could be regulated by the prevailing oxygen tension in the ischaemic arrhythmic heart. Essentially the pro drug activation of lignocaine N-oxide may be triggered by the ischaemic state of the heart and terminated as the oxygen content in the heart returns to a more normal level. A controlled release and site-specific active drug delivery of lignocaine N-oxide, a hypoxia-mediated antiarrhythmic agent, may thus be achieved.

El canvi en l’estil de vida que s’ha produït en les societats desenvolupades els darrers anys ha tingut com a contrapartida l’aparició de conductes sedentàries i modificacions en la dieta. Com a conseqüència d’aquests factors s’han produït diverses alteracions metabòliques que han causat un augment de la prevalença de l’obesitat. Aquesta obesitat té una sèrie d’efectes adversos sobre la fisiologia cardiovascular i és considerada un important factor de risc pel desenvolupament de la insuficiència cardíaca. De fet, el consum de dietes amb un elevat contingut en greixos (HFD) s’ha relacionat amb una sèrie d’alteracions cardíaques directes com són la inflamació, la hipertròfia i la disfunció contràctil. Durant el procés inflamatori que es produeix en les esmentades malalties cardiovasculars, les cèl•lules cardíaques humanes secreten citocines i quimiocines proinflamatòries com el TNF-α, MCP-1, i IL-6, molècules que es troben sota el control transcripcional del factor de transcripció ubic i induïble anomenat NF-κB. Aquestes citocines exerceixen diversos efectes pleiotròpics autocrins en les cèl•lules cardíaques, tot produint un efecte de retroalimentació positiva del procés inflamatori que contribueix al desenvolupament d’aquestes malalties. En condicions normals, el cor de mamífers adults obté energia en forma d’ATP principalment a partir de la β-oxidació d’àcids grassos en el mitocondri, encara que aquest orgànul és capaç de catabolitzar altres substrats com la glucosa o el lactat per tal d’assegurar una font constant d’energia. Ara bé, en determinades circumstàncies, com és el cas de la hipertròfia i la insuficiència cardíaques, aquesta flexibilitat de substrat es veu compromesa i la β-oxidació d’àcids grassos es redueix degut a que la font principal d’energia passa a ser la glucosa. Aquests canvis metabòlics comporten una desregulació del control transcripcional de gens relacionats amb el transport, captació i catabolisme dels àcids grassos i la glucosa. En el miocardi, els factors de transcripció implicats en el control d’aquests gens inclouen ERRα i PPARβ/δ. Ambdós factors de transcripció, participen en l’activació de la PDK4, enzim clau en la modulació homeostàtica de la glucosa. Aquesta cinasa regula l’activitat de la PDC, enzim que catalitza la reacció de descarboxilació del piruvat a acetil-CoA, tot limitant l’ús de carbohidrats com a font d’energia en mitocondris i afavorint així la β-oxidació d’àcids grassos. En l’activació de la transcripció de PDK4 també hi participa PGC-1α, que interacciona amb ERRα i PPARβ/δ, tot incrementant-ne la seva activitat transcripcional. Estudis recents però, semblen indicar que no només aquests dos factors de transcripció participen en la regulació de PDK4. És el cas d’E2F1, un factor de transcripció clau en la regulació de la transició de la fase G1 a la fase S del cicle cel•lular i del qual la regió promotora del gen que codifica per PDK4 en presenta dos llocs d’unió. Estudis recents suggereixen que PPARβ/δ, que és la forma predominant en les cèl•lules cardíaques, pot atenuar les vies de senyalització inflamatòries i, per tant, interferir en la remodelació cardíaca. Aquesta funció és en gran mesura deguda a la capacitat dels PPAR, un cop han estat activats per agonistes, de formar complexos amb altres factors de transcripció activats, com ara NF-κB i STAT resultant així en la inhibició de l’activitat transcripcional d’aquests últims. Així l’ús d’agonistes PPARβ/δ podria ser un camí força interessant de cara a trobar potencials fàrmacs per tal de pal•liar les afeccions cardíaques derivades d’alteracions metabòliques i amb un rerefons inflamatori. En conjunt en aquest treball es presenten una sèrie de resultats destinats a conèixer de forma més detallada els mecanismes moleculars que relacionen les alteracions metabòliques i els processos inflamatoris en cor, per tal de poder buscar potencials dianes farmacològiques amb l’objectiu de prevenir i tractar aquests estats patològics.
The change in lifestyle that has occurred in developed societies in recent years has been accompanied by the rise of sedentary behavior and changes in diet that have caused an increasing obesity prevalence. Obesity has a huge number of adverse effects on cardiovascular physiology and is considered an important risk factor for heart failure developement. In fact, high fat diets have been linked with direct cardiac abnormalities such as inflammation, hypertrophy and contractile dysfunction. During the inflammatory process that occurs in these diseases, human cardiac cells secrete proinflammatory cytokines and chemokines such as TNF-α, MCP-1, and IL-6, molecules that are under the control of the ubiquitous and inducible transcription factor NF-κB. In certain circumstances, such in hypertrophy and heart failure, the substrate flexibility in heart is compromised and the fatty acids β-oxidation is reduced because the main source of energy becomes the glucose. These metabolic changes lead to a deregulation on the transcriptional control of genes associated with transport, uptake and catabolism of fatty acids and glucose. In the myocardium, among the transcription factors involved in the control of these genes we found ERRα and PPARβ/δ. Both transcription factors, are involved in PDK4 activation, an important enzyme in the homeostatic modulation of glucose. This kinase regulates PDC activity, an enzyme that catalyzes the decarboxylation from pyruvate to acetyl-CoA, limiting the use of carbohydrates as energy source in mitochondria and thus favoring the fatty acid β-oxidation. In the PDK4 transcription activation also participates PGC-1α, which interacts with ERRα and PPARβ/δ, increasing its transcriptional activity. However recent studies, suggest that not only these two transcription factors are involved in PDK4 regulation. Other transcription factors as E2F1, which is crucial for cell cycle control, may regulate PDK4 expression. Overall, the results shown in this work are aimed to learn in more detail the molecular mechanisms linking the metabolic disorders and inflammatory processes in heart, in order to find potential drug targets to prevent and treat these pathological states.

Heart-type Fatty Acid-Binding Protein (H-FABP) is required for high rates of skeletal muscle long chain fatty acid (LCFA) oxidation and esterification. Here we assessed whether H-FABP affects soleus muscle glucose uptake when measured in vitro in the absence of LCFA. Wild type and H-FABP null mice were fed a standard chow or high fat diet before muscle isolation. With the chow, the mutation increased insulin-dependent deoxyglucose uptake by 141% (P<0.01) at 0.02 mU/ml of insulin, but did not cause a significant effect at 2 mU/ml insulin; skeletal muscle triglyceride and long chain acyl-CoA (LCACoA) levels remained normal. With the fat diet, the mutation increased insulin-dependent deoxyglucose uptake by 190% (P<0.01) at 2 mU/ml insulin, thus partially preventing insulin resistance, and completely prevented the threefold (P<0.001) diet-induced increase of muscle triglyceride levels; however, muscle LCACoA levels showed little or no reduction. With both diets, the mutation reduced the basal (insulinindependent) soleus muscle deoxyglucose uptake by 28% (P<0.05). These results establish a close relationship of FABP-dependent lipid pools with insulin sensitivity, and indicate the existence of a non-acute, antagonistic, and H-FABP-dependent fatty acid regulation of basal and insulin-dependent muscle glucose uptake. Liver fatty acid binding protein (L-FABP) has been proposed to limit the availability of chain LCFA for oxidation and for peroxisome proliferator-activated receptor (PPAR-alpha), a fatty acid binding transcription factor that determines the capacity of hepatic fatty acid oxidation. Here, we used L-FABP null mice to test this hypothesis. Under fasting conditions, this mutation reduced β-hydroxybutyrate (BHB) plasma levels as well as BHB release and palmitic acid oxidation by isolated hepatocytes. However, the capacity for ketogenesis was not reduced: BHB plasma levels were restored by octanoate injection; BHB production and palmitic acid oxidation were normal in liver homogenates; and hepatic expression of key PPAR-alpha target (MCAD, mitochondrial HMG CoA synthase, ACO, CYP4A3) and other (CPT1, LCAD) genes of mitochondrial and extramitochondrial LCFA oxidation and ketogenesis remained at wild-type levels. These results suggest that under fasting conditions, hepatic L-FABP contributes to hepatic LCFA oxidation and ketogenesis by a nontranscriptional mechanism.

Although pathological alterations in gene expression and mitochondria function in response to cardiac ischemia are well recognized, the mechanisms driving these changes are incompletely understood. Nuclear to mitochondrial communication regulating gene expression and mitochondrial function is a critical process following cardiac ischemic injury. Here we determine that cyclin C, a component of the transcriptional regulator, Mediator complex, directly regulates cardiac and mitochondrial function by modifying mitochondrial fission. We tested the hypothesis that cyclin C has a binary function as a transcriptional cofactor in the nucleus and acute regulation of cardiac energetics in ischemia by enhancing mitochondrial fission in the cytoplasm. In response to stress, cyclin C translocates to the cytoplasm enhancing mitochondria fission in part through interactions with Cdk1. Using cardiac specific cyclin C knockout and overexpression mouse models, we determined cyclin C regulates mitochondria morphology under basal and ischemic conditions in vivo. Furthermore, pretreatment with a Cdk1 inhibitor followed by ischemia in vivo results in reduced mitochondrial fission. Together, our study reveals that cyclin C regulates both hypertrophic gene expression and mitochondrial fission providing new insights into the regulation of cardiac energy metabolism following acute ischemic injury.

Orientador: Antonio Ari Gonçalves
Tese (doutorado) - Universidade Estadual de Campinas, Instituto de Biologia
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Resumo: Objetivos: Metformina e glibenclamida são fármacos utilizados para diminuir a glicemia de diabéticos tipo 2. Metformina reduz a absorção gastrintestinal de glicose e a gliconeogênese hepática e aumenta a captação de glicose periférica. Por sua vez, glibenclamida aumenta a liberação de insulina após bloquear canais de K+. Apesar destes efeitos, metformina em altas concentrações e glibenclamida podem influenciar o sistema cardiovascular e acelerar a progressão de doenças vasculares, predispondo o coração à falência cardíaca ou infarto. Estas e outras mudanças fisiológicas podem ser associadas a um ECG anormal, mostrando aumento do intervalo QT e de sua dispersão (QTd). Estas mudanças podem ser associadas a um baixo limiar para arritmias ventriculares e provocar morte súbita durante isquemia. Neste estudo avaliamos os efeitos do tratamento com metformina e/ou glibenclamida em ratos diabéticos por aloxana sobre os intervalos do ECG: QT e suas derivadas QTc, QTd, e QTcd. Em outra série experimental avaliamos a pressão desenvolvida pelo ventrículo esquerdo (LVP) e as suas derivadas (DP/Dt+ e DP/Dt-), usando a preparação de Langendorff utilizando coração isolado de ratos diabéticos. A isquemia foi provocada pela perfusão (1 h) com noradrenalina (NE). Além disso, o glicogênio foi medido em coração de ratos antes e após perfusão com noradrenalina. As alterações histológicas no ventrículo também foram estudadas. Métodos: Ratos Wistar machos, diabéticos por aloxana, foram tratados com metformina (3,5, 30 e 74 mg.g-1 de peso corporal ¿ p.c) ou glibenclamida (0,10 mg/g-1 p.c) e/ou glibenclamida e metformina (0,10 + 3,5 mg.g-1 p.c), simultaneamente durante 30 dias. O ECG foi registrado no 15o e 30o dia de tratamento. No 30º dia, sob anestesia, o coração foi isolado e perfundido com solução de Krebs-Henseleit em um aparelho de Langendorff. A isquemia foi induzida com noradrenalina 10-6 M (2 ml.min-1.g-1) mantida durante 1 h na solução perfusora. O glicogênio tecidual (mg.100.mg-1) foi extraído de fragmentos de ventrículo de ratos em repouso ou após a perfusão. O glicogênio foi medido pelo método do fenol sulfúrico. Em outros grupos de ratos, preparados de modo idêntico, os corações foram removidos sob anestesia e fixados em formoldeído em tampão PBS. Secções de ventrículo foram preparadas depois de embebidas em parafina e em seguida, os cortes foram fixados em lâminas e corados pelo método hematoxilina eosina (HE). O ensaio do glicogênio ventricular foi feito usando o método ácido de Schiff. Os núcleos foram contados e as suas áreas foram medidas (mm2). Os grânulos de glicogênio foram detectados pela coloração violeta do citoplasma, usando o método de schiff (PAS positivo) e fotografados. Resultados: Após 15 e 30 dias, a glicemia, o intervalo QT e as suas derivadas aumentaram nos ratos diabéticos. Após 30 dias, a glicemia diminuiu em ratos diabéticos que foram tratados com doses baixa ou intermediária de metformina (3,5 e 30 mg.g-1 p.c.), ou com glibenclamida e com a combinação glibenclamida + metformina (3,5 mg.g-1 p.c.). Entretanto, o grupo tratado com a dose mais alta de metformina (74 mg.g-1 p.c) não teve a sua glicemia diminuída. Por outro lado, nos ratos tratados com doses: baixa ou intermediária de metformina os intervalos do ECG: QTc, QTd e QTcd foram reduzidos, em relação ao grupo diabético tratado com a maior dose de metformina. Estes resultados também produziram melhores efeitos em comparação aos grupos diabéticos tratados com glibenclamida e nos grupos tratados com a associação glibenclamida e metformina. Doses baixas, intermediárias e altas (3,5, 30 e 74 mg.g-1 p.c.) de metformina aumentou o armazenamento de glicogênio no ventrículo de ratos diabéticos de 0,19 ± 0,007 (controle) para 0,38 ± 0,007 mg.100 mg-1, 0,5 ± 0,05 mg.100 mg-1 e 0,7 ± 0,04 mg.100 mg-1 (p< 0,05), respectivamente. Quanto à pressão sistólica ventricular, houve rápido aumento da pressão logo no inicio da perfusão com NE no grupo controle, com pico de pressão a 145 ± 9,7 mmHg), seguido de lenta queda até 99 ± 3 mmHg. Esta tendência foi observada também nas derivadas DP/Dt+ e DP/Dt-. Metformina (3,5 e 30 mg.g-1 p.c) e glibenclamida isoladamente ou em associação com metformina protegeram o músculo cardíaco durante a isquemia, não diferindo do grupo controle. Contudo, ratos diabéticos não tratados ou tratados com a maior dose de metformina, desenvolveram pressão sistólica máxima inferior a todos os grupos experimentais, revertendo aos níveis basais mais rapidamente que nos demais grupos. As derivadas DP/Dt+ e DP/Dt- mostraram curvas semelhantes. Após a isquemia, o glicogênio diminuiu em todos os grupos, sendo 0,09 ± 0,007 no grupo controle; 0,1 ± 0,006 nos diabéticos e 0,6 ± 0,005 nos diabéticos tratados com 74 mg.g-1 pc de metformina. O tratamento com glibenclamida e/ou metformina diminuiu o estoque de glicogênio de 0,62 ± 0,05 mg.100 mg-1 para 0,19 ± 0,05 mg.100 mg-1 e de 0,74 ± 0,03 mg.100 mg-1 para 0,22 ± 0,008 mg.100 mg-1, respectivamente. Entretanto, a utilização de glicogênio foi proporcional em todos os grupos. A análise morfológica demonstrou um aumento na quantidade dos núcleos no coração de ratos diabéticos de 21,33 ± 1.17 (no grupo controle) para 36,6 ± 5 (p< 0,05) e redução na média da área dos núcleos, de 0,16 ± 0,02 (controle) para 0,08 ± 0,01 (p< 0,05). No grupo tratado com a menor concentração de metformina (DM 3.5) diminuiu a quantidade de núcleos de 36,6 ± 5 (grupo diabético) para 22,8 ± 2 (p< 0,05), porém aumentou a média da área dos núcleos de 0,08 ± 0,01 mm2 para 0,17± 0,01 mm2 (p< 0,05). Nos grupos tratados com as maiores doses de metformina (30 e 74 mg.g-1 p.c.), a quantidade de núcleos aumentou para 34,16 ± 1,85 e 47,29 ± 2,92, respectivamente), e suas respectivas áreas aumentaram para 0,86 ± 0,05 e 0,5 ± 0,06, diferindo dos grupos controle e dos diabéticos não tratados. Nos grupos diabéticos tratados com glibenclamida e glibenclamida + metformina, as áreas dos núcleos aumentaram de 0,08 ± 0,01 mm2 para 0,71 ± 0,09 mm2 e 0,67 ± 0,01 mm2, respectivamente, (p< 0,001). Conclusões: O aumento na dispersão dos intervalos QT com o tratamento pode significar um risco de arritmia que predispõe ratos à morte súbita. Os resultados da pressão obtidos pelo método de Langendorff indicam que a força de contração diminuiu durante o período de isquemia por NE, sugerindo que o coração estava mais rígido. Estes resultados permitem-nos deduzir que as maiores doses de metformina, 74 mg.g-1 indicados como as máximas para humanos, podem causar sérios prejuízos ao trabalho cardíaco em caso de sobrecarga. Por outro lado, altas doses de metformina, de glibenclamida e a associação entre estas drogas aumentam a quantidade e o tamanho dos núcleos. Conseqüentemente, o ventrículo hipertrofia, em decorrência do aumento da atividade celular, prejudicando de modo importante, a estrutura e a função cardíaca. Portanto, este aumento de glicogênio está associado à severidade e à duração do diabetes. Assim, o coração torna-se altamente susceptível à isquemia
Abstract: Metformin and glibenclamide are pharmacos used to decrease blood glucose on type 2 diabetics. Metformin decreases gastrointestinal absorption of glucose and gluconeogenesis and increases peripheric glucose uptake. Glibenclamide increases insulin secretion by blocking K+ channels. Besides these effects, metformin and glibenclamide may influence cardiovascular system, which accelerate the progression of vascular disease, predisposing heart to failure or infarct. These abnormalities associated to physiological changes may generate an abnormal ECG, with an increased QT interval and its correspondent dispersion (QTd). These changes could be associated to a lower threshold for malignant ventricular arrhythmias and a sudden death by ischemia. The aim of this study was to evaluate the effects of metformin and/or glibenclamide treatment on QT intervals and its derivatives: QTc, QTd, and QTcd. We also evaluated the pressure developed by left ventricle (LVP) and calculate the correspondents derivatives (DP/Dt+ and DP/Dt-) on heart isolated from diabetic rats, under ischemia caused by norepinephrine (NE). Glycogen was measured after ischemia and compared to control heart, non-submitted to NE. We also analyzed the histological changes in ventricle cells. Methods: Male Wistar diabetic rats were treated by metformin (3.5, 30 and 74 µg.g-1 b.w) or glibenclamide (0.13 µg.g-1 b.w) and its association to metformin (0.13 µg.g-1 b.w + 3.5 µg.g-1 b.w) during 30 days. A 6-lead ECG was recorded initially and after 15 and 30 days treatment. At the end, under anaesthesia, heart were isolated and perfused by Krebs-Henseleit solution in a Langendorff apparatus. Ischemia were induced by adding norepinephrine 10-6 M to the solution (2 ml.min-1.g) during 1 h. Glycogen (mg.100 mg-1 wet tissue) was measured on heart at rest or after perfusion, using the fenol sulfuric method. In another group, after anaesthesia hearts were removed, cleaned and fixed in phormoldheyde in PBS buffer. Thin ventricle sections were made and after paraffin embedding, fine slices were cut and stained with hematoxilin eosin (HE). Ventricle glycogen assay was performed on those slides using the acid Schiff process. The number of nuclei was counted out and nuclei area was measured (mm2). Glycogen granules were recognized the violet colored cytoplasm. Results: After 15 and 30 days, glycemia, QT interval and its derivates increased on diabetic rats. On the other hand, diabetic rats treated during 30 days by low and intermediate doses of metformin (3.5 and 30 µg.g-1 b.w.) or glibenclamide or glibenclamide plus metformin, all decreased glycemia. However, the group treated with the highest dose of metformin (74 µg.g-1 b.w) failed to reduce glycemia. On the other hand, the groups treated by low and intermediate doses reduced the ECG intervals: QTc, and QTd, and QTcd, in contrast to the diabetic group treated with the highest metformin dose and the groups treated by glibenclamide and glibenclamide associated to metformin. Metformin, in low and high doses (3.5, 30 and 74 mg.g-1 b.w.) increased glycogen storage on diabetic rat ventricle, from 0.19 ± 0.007 (control group) to 0.38 ± 0.007 mg.100 mg-1, 0.5 ± 0.05 mg.100 mg-1 and 0.7 ± 0.04 mg.100 mg-1, p< 0.05, respectively. The treatment with glibenclamide alone or associated to metformin increased glycogen, too. In the control group, isolate hearts showed a rapid increase on ventricular pressure, just initiation of NE perfusion (145 ± 9.7 mmHg), followed by a slow fall to 99 ± 3 mmHg. Similar changes was found on the derivates DP/Dt+ and DP/Dt-. Metformin (3.5 and 30 mg.g-1), glibenclamide and glibenclamide associated to metformin protected cardiac muscle during ischemia, similarly to the control group (p> 0.05). But, the non-treated diabetic group and the group treated by 74 mg.g-1 of metformin, produced a maximal pressure which were inferior to the control group and the reversion of the LVP, DP/Dt+ and DP/Dt- was faster than that of the control group. After ischemia, glycogen was reduced on all groups to 0.09 ± 0.007 mg.100 mg-1 on control group; 0.1 ± 0.006 mg.100 mg-1 on diabetic group and 0.06 ± 0.005 mg.100 mg-1 on DM74. However, this decrease was inferior to that of the group treated by the highest dose. The treatment with glibenclamide alone and associated to metformin diminished glycogen storage from 0.62 ± 0.05 mg.100 mg-1 to 0.19 ± 0.05 mg.100 mg-1 and 0.74 ± 0.03 mg.100 mg-1 to 0.22 ± 0.008 mg.100 mg-1. However its utilization was proportional for all groups. Heart submitted to ischemia decreases its reserve, (p< 0.05 compared to non-ischaemic). These results suggested that high doses metformin, in special 74 mg.g-1 b.w., indicated as maximal for humans, makes heart prompt to ischemia. Diabetic rat hearts showed an increase on the amount of nuclei, from 21.33 ± 1.17 to 36.6 ± 5 (p< 0.05) and a reduction of its area, from 0.16 ± 0.02 mm2 to 0.08 ± 0.01 mm2 (p< 0.05) in comparison to the control group. The lowest dose of metformin (DM 3.5) diminished the amount of nuclei (36.6 ± 5 vs 22.8 ± 2; p< 0.05) and increased theirs size (0.08 ± 0.01 vs 0.17± 0.01). The amount of nuclei increased to 34.16 ± 1.85 and 47.29 ± 2.92 during the treatment with high metformin doses, (30 and 74 mg.g-1 b.w., respectively), and the nuclei area increased to 0.86 ± 0.05 mm2 and 0.5 ± 0.06 mm2, respectively, differing from control and non-treated diabetic groups. Similar result, was obtained on the group treated by glibenclamide and/or metformin, on cardiac cells, which the nuclei area increased to 0.71 ± 0.09 mm2 and 0.67 ± 0.01 mm2, respectively, (p< 0.001). Conclusions: The increased dispersion of QT intervals during treatment may be subjacent to the risks of arrhythmias that predispose humans to sudden death. Results shown on Langendorff methodology indicate that contraction force decreased, suggesting that ventricle muscle were prone to ischemia. Then, high metformin doses (74 mg.g-1), as indicated for humans, may cause damage to cardiac work during overload. High metformin doses, glibenclamide and glibenclamide associated to metformin increase the number of nuclei, as well, theirs size. Consequently, the ventricle hypertrophy due to an increased cellular activity may cause important injuries to cardiac structure and function. We can conclude that, the increased glycogen content on ventricle was associated to the severity and the duration of diabetes. Then, heart became more susceptible to the ischemia effects
Doutorado
Fisiologia
Doutor em Biologia Funcional e Molecular

Hypoxia inducible factor-1α (HIF-1α) plays a critical role in the oxygen homeostasis of all metazoans. HIF-1α is a master transcriptional regulator which coordinates the adaptive response to low oxygen tension. Through activation of a plethora of downstream target genes, HIF-1α facilitates oxygenation by promoting angiogenesis and blood vessel dilation, in addition to modulating metabolic pathways to inhibit oxidative phosphorylation and promote glycolytic energy production. Given the critical roles of hypoxia, insufficient blood supply and perturbed energetics in the pathogenesis of cardiovascular disorders, notably ischaemic heart disease, therapeutic modulation of HIF-1α is of significant clinical interest. Previous studies have demonstrated an acute cardioprotective role for both endogenous and supraphysiological HIF-1α signalling in the context of myocardial ischaemia. In contrast, chronic supraphysiological HIF-1α activation in the unstressed heart has been shown to induce cardiac dysfunction. To address the effect of chronic endogenous HIF-1α activation post-myocardial infarction (MI), the present work employed a murine coronary artery ligation (CAL) model in conjunction with temporally-inducible, cardiac-specific deletion of Hif-1α. While CAL surgery successfully modelled myocardial infarction – eliciting substantial adverse cardiac remodelling and contractile dysfunction – there was no evidence of chronic HIF-1α activation by CAL in HIF knockout or control left ventricular samples. In keeping with this, chronic ablation of Hif-1α (from 2 weeks post-CAL) had no discernible additional effect upon cardiac function. Overall, these findings do not support a potential therapeutic role for inhibition of HIF-1α signalling in the chronic phase post-MI. The fundamental tricarboxylic acid (TCA) cycle enzyme fumarate hydratase (FH) converts fumarate to malate. FH deficiency is associated with smooth muscle and kidney tumours which exhibit normoxic HIF signalling due to fumarate accumulation. To investigate the potential for fumarate accumulation to elicit protective HIF signalling, a cardiac-specific Fh1 null mouse was developed through Cre-loxP recombination. Strikingly, despite interruption of the TCA cycle in a highly metabolically demanding organ, cardiac Fh1 null mice were viable, fertile and survived into adulthood, demonstrating the remarkable metabolic plasticity of the heart. However, by 3-4 months Fh1 null mice develop a lethal cardiomyopathy characterised by cardiac hypertrophy, ventricular dilatation and contractile dysfunction. Despite lack of a pseudohypoxic response, Fh1 null hearts did exhibit another phenomenon observed in FH-deficient cancers and also attributed to fumarate accumulation – activation of the nuclear factor (erythroid-derived 2)-like 2 (NRF2) antioxidant pathway. Heterozygous, but not homozygous, somatic deletion of Nrf2 extended the life expectancy of cardiac Fh1 null mice. Exploration of redox status revealed a more reductive environment in Fh1 null hearts than controls. As a corollary, inhibition of the rate limiting enzyme of the pentose phosphate pathway – a major source of cellular reducing equivalents – with dehydroepiandrosterone conferred striking amelioration of the Fh1 null cardiomyopathy, suggesting a possible pathogenic role for reductive stress. While loss of mitochondrial Fh1 activity and subsequent TCA cycle dysfunction likely contribute to the Fh1 null phenotype, the importance of cytosolic FH was unclear. To clarify this, FH was expressed specifically in the cytosol in vivo. This was sufficient to substantially rescue the Fh1 null cardiomyopathy, supporting a role for cytosolic FH disruption in its pathogenesis. Taken together, these findings highlight the potential for reductive stress to contribute to cardiac dysfunction and suggest a function for cytosolic FH in cardiac metabolic homeostasis.

In our studies we found that stabilized expression of HIF-1α in heart led to better recovery of function and less tissue death after 30 minutes of global ischemia, via mechanisms that preserve the mitochondrial polarization. Our group previously showed that HIF-1α conferred ischemic tolerance by allowing cardiomyocytes to use fumarate as an alternative terminal electron acceptor to sustain anaerobic mitochondrial polarization. The source of fumarate was identified as the purine nucleotide cycle (PNC). Here we discovered that HIF-1α upregulates AMP deaminase 2 (AMPD2), the entry point to the PNC. The combination of glycolysis and the PNC may protect the heart's nucleotide resources. We subsequently examined the effects that HIF-1α exerts on nucleotide metabolism in the ischemic heart. We found that HIF-1α expression reduces adenosine accumulation in the ischemic heart. As ATP is depleted during ischemia, AMP accumulates. Our results suggest that AMP metabolism is shunted towards AMPD2 rather than the adenosine producing 5'-nucleotidase pathway. Subsequently, we treated hearts with the PNC inhibitor hadacidin followed by 30 minutes of global ischemia. Inclusion of hadacidin reduced ATP and adenylate energy charge in the hearts. These findings allow us to propose that activity of the PNC prevents the F0F1 ATP synthase from consuming glycolytic ATP in order to maintain mitochondrial polarization during ischemia. Thus, the PNC provides ATP sparing effects and preserves the energy charge in the ischemic heart. The fact that ATP and adenylate energy charge is better preserved during the initial 20 minutes of ischemia in HIF-1α expressing hearts is supportive of our observation that HIF-1α upregulates the PNC. HIF-1α also upregulates adenosine deaminase, which degrades adenosine. The limitation of adenosine accumulation may help HIF-1α expressing hearts avoid toxicity due to chronic adenosine exposure. Finally, we found that HIF-1α induces the expression of the nucleotide salvage enzyme hypoxanthine phosphoribosyl transferase (HPRT). Upon reperfusion HPRT serves to reincorporate the nucleotide degradation product, hypoxanthine, into the adenylate pool and may prevent the production of reactive oxygen species. Collectively, HIF-1α robustly protects the heart from ischemic stress and it upregulates several pathways whose cardioprotective role may extend beyond the remodeling of nucleotide metabolism.

Type 2 diabetic patients have impaired cardiac ischaemia-reperfusion recovery and higher rates of mortality following a myocardial infarction. Hypoxia is a key component of ischaemia and therefore, this thesis is aimed to investigate the effect of hypoxia on metabolism and contractile function of the type 2 diabetic heart. In combination with high fat feeding, different doses of streptozotocin (STZ) (15, 20, 25 and 30 mg/kg) were used to determine the optimal dose needed for induction of diabetes in male Wistar rats. A novel type 2 diabetic model was developed and characterised by hyperinsulinaemia, hyperglycaemia and dyslipidaemia. The effects of chronic hypoxia were investigated by housing diabetic rats in a hypoxic chamber (11% O2) for 3 weeks. Results showed that the HIF signalling pathway was not impaired in diabetic hearts. PPARa targets (MCAD, UCP3 and PDK4) were downregulated by chronic hypoxia in control hearts but not in diabetic hearts, suggesting PPARa overactivation in diabetic hearts. Acute hypoxic perfusions (16 minutes normoxia, 36 minutes hypoxia and 20 minutes reoxygenation) were performed to investigate the effect of acute hypoxia on metabolism and cardiac function. Diabetic hearts had impaired metabolic response to acute hypoxia, associated with decreased cardiac function during acute hypoxia and reoxygenation. In the final study, sulfo-N-succinimidyl oleate (SSO), a FAT/CD36 inhibitor was administered prior to acute hypoxia to modulate metabolism in diabetic hearts. The previously seen maladaptation of diabetic hearts to acute hypoxia was improved by SSO. In diabetic hearts, SSO increased glycolysis during acute hypoxia, and normalised fatty acid oxidation and decreased triglyceride deposition upon reoxygenation, associated with improved cardiac function at the end of experiment compared to untreated diabetic hearts. In conclusion, the elevated lipid metabolism contributed to metabolic inflexibility in diabetic hearts, which is associated with the impaired response to hypoxia, and the inhibition of lipid metabolism was associated with improved cardiac function in diabetic hearts following hypoxia.

Cardiac muscle function necessitates the meticulous assembly and interactions of several cytoskeletal and regulatory proteins into specialized structures that orchestrate contraction and transmission forces. Despite extensive studies identifying the protein components responsible for these important aspects of heart development, putative RNA based mechanisms remain poorly understood, even with their demonstrated importance in other tissues. Evidence suggests that post-transcriptional regulation is critical for muscle function, but the molecular players involved (RNA binding proteins and mRNA targets) have remained elusive. We investigated the molecular mechanisms and targets of the muscle-specific Fragile X Related protein-1 (FXR1), an RNA binding protein whose absence leads to perinatal lethality in mice. Loss of FXR1 results in global protein level alterations. Morphological and biochemical analyses of Fxr1^(-/-) mice revealed severe disruption of intercalated disc and costamere architecture and composition. We identified several candidate mRNAs specifically enriched in the FXR1 protein complex. Two targets that likely contribute to the architectural defects are desmoplakin (dsp) and talin2 (tln2). In vitro assays indicate that FXR1 binds to these mRNA targets directly and represses their translation. Additionally, we provide preliminary evidence that the Fxr1^(-/-) mice mimic a hypothyroid state of cardiac gene expression, with alterations in myosin heavy chain and troponin I isoforms. Our findings reveal the first mRNA targets of FXR1 in muscle and support translational repression as a novel mechanism for cardiac muscle development and function.

Includes bibliographical references (21 leaves). Previous studies have found that green tea and its antitoxidant constituents, the catechins, are hypocholesterolaemic in both epidemiological and animal intervetion studies. The main objectives of the present study were to investigate the mechanism by which green tea and its most abundant catechin constituent epigallocatechin gallate increase the low-density lipoprotein (LDL) receptor of HepG2 cells. In addition, it was hoped to determine if a crude catechin extract from green tea could lower plasma cholesterol levels in the hypercholesterolaemic rabbit and ascertain if this effect was due to an increase in the LDL receptor. The study provides evidence that green tea and its catechins exhibit hypocholesterolaemic properties and may therefore provide protection against heart disease.

Hiperglicemia está associada a mal prognóstico nas doenças crônicas e agudas, mas poucos estudos abordaram a glicemia durante a ressuscitação cardiopulmonar. Objetivo: Avaliar a evolução da glicemia em modelo de parada cardíaca similar ao atendimento atual dos casos de morte súbita extra-hospitalar. Métodos: Em estudo prospectivo, randomizado e cego, fibrilação ventricular foi induzida em 32 animais. Após 7 min, suporte de vida padrão foi iniciado e mantido até o retorno da circulação espontânea ou por 30 min no máximo. Os animais foram randomizados em três grupos, de acordo com o fármaco aplicado: Epinefrina (n=12), Vasopressina (n=12) ou Salina (n=8). A glicemia basal foi mensurada e novamente aos 4 min, 8 min, após o primeiro choque aos 9 min (coincidindo com a 1ª dose de fármaco) e a cada 5 min. Resultados: O retorno da circulação espontânea ocorreu em 19 animais: grupo Epinefrina 10/12, vasopressina 7/12 e Salina 2/8, diferença significante somente entre Epinefrina e Salina (p=0,019). A evolução foi típica ao longo do suporte de vida em todos os grupos, com grande aumento da glicemia ocorrendo também no grupo controle. A cada instante, com apenas 2 min de suporte de vida, a glicemia dos animais que sobreviveram à parada cardíaca foi maior do que a glicemia dos animais que não sobreviveram (229 ± 15 mg/dL vs. 182 ± 15 mg/dL; p=0,041). Esta diferença foi notada aos 9 min, antes da 1ª dose de fármaco e se manteve ao longo de todo o experimento, com pico aos 14 min (263 ± 20 mg/dL vs. 178 ± 16 mg/dL; p=0,006). Conclusões: Houve uma evolução típica, com hiperglicemia durante a ressuscitação cardiopulmonar e concentrações maiores de glicose se associaram à sobrevivência da parada cardíaca.
Although hyperglycemia is associated with poor outcomes in emergency conditions, limited data exist regarding the effects of serum glucose on cardiopulmonary resuscitation (CPR). Methods and Results: In a prospective, blinded animal study, ventricular fibrillation was induced in 32 pigs. Standard CPR was initiated at 7 min and continued for up to 30 min or until the return of spontaneous circulation (ROSC). The animals were randomly assigned into three groups according to the medication administered: epinephrine (n=12), vasopressin (n=12), and saline (n=8). The serum glucose was measured at baseline, 4 min, 8 min, 9 min (immediately after the first shock), with the first dose of medication, and then every 5 min. ROSC occurred in 19 pigs: in 10/12 of the epinephrine group, 7/12 of the vasopressin group, and 2/8 of the saline group. A significant difference in the ROSC rate was found only between the epinephrine and saline groups (p=0.019). The serum glucose presented a typical pattern; hyperglycemia was present in all the groups and was higher in those animals that achieved ROSC, independent of the drug administered (229 ± 15 mg/dL vs. 182 ± 15 mg/dL; p=0,041). This difference was first noticed at 9 min and the largest difference occurred at 14 min, after 7 min of CPR, and 5 min after the first medication (263 ± 20 mg/dL vs. 178 ± 16 mg/dL; p=0,006). Conclusions: In an experimental VF study, there was a typical hyperglycemic response pattern during CPR, and higher glucose levels were associated with ROSC.

Orientador: Guilherme de Camargo Ferraz
Marcos Jun Watanabe
José Corrêa de Lacerda Neto
Resumo: Objetivou-se caracterizar a frequência cardíaca máxima (FCMÁX), a intensidade da prova de marcha oficial e comparar o custo de transporte (COT) e a energia metabólica (P) de equinos da raça Mangalarga Marchador (MM) de marcha picada (MP) ou batida (MB). Ao todo 22 equinos da raça MM participaram deste estudo. O experimento foi realizado em três fases: 1) teste de esforço máximo (TEM), 2) provas oficiais de marcha (POM) e 3) teste padronizado de marcha (TMP). Para caracterizar a FCMÁX, 19 equinos (14 de MB e 5 de MP) realizaram um TEM. Destes, 13 (9 de MB e 4 de MP) foram monitorados durante a POM que foi composta por 4 etapas: marcha, passo, prova funcional e estação. A média da FC de cada etapa da POM foi relacionada à FCMÁX para determinação da sua intensidade relativa. O TPM foi realizado com 14 equinos (9 de MB e 5 de MP), dos quais 11 já haviam participado das etapas anteriores. O COT e P foram calculados a partir dos valores de frequência cardíaca (FC) obtidos durante o TMP. Amostras sanguíneas foram coletadas para análise da concentração plasmática de lactato [Lac]. Aplicou-se o teste t de student e ANOVA de uma via seguida pelo teste Holm-Sidak (P<0,05). A FCMÁX média foi de 211±11 e 214±11 bpm para os grupos MB e MP, respectivamente, não havendo diferença (P>0,05) entre eles. A [Lac] aumentou em decorrência do TEM, sem diferença entre os grupos. Isto indicou que os grupos possuíam a mesma aptidão física. As etapas da POM definidas no nosso estudo diferiram quanto à i... (Resumo completo, clicar acesso eletrônico abaixo)
Abstract: This study aimed to characterize the maximum heart rate (HRMÁX), the intensity of the official marcha test (OMT) and compare the cost of transport (COT) and metabolic power (P) of Mangalarga Marchador (MM) horses of marcha batida (MB) and marcha picada (MP). Twenty-two MM horses participated in this study. The experiment was conducted in three phases: 1) maximal effort test (MET), 2) official marcha test (OMT) and 3) standardized walk test (SWT). To characterize the HRMÁX, 19 horses (14 MB and 5 MP) underwent a MET. Of these, 13 (9 MB and 4 MP) were monitored during the OWT that consisted of 4 stages: walk, marcha, functional test and rest. The average HR in each stage of OMT was correlated to the HRMÁX to determine their relative intensity. The SWT was performed with 14 horses (9 MB and 5 MP), of which 11 had already participated in the previous stages. The COT and P were calculated from the heart rate values (HR) obtained during the SWT. Blood samples were collected to analyze plasma lactate concentration [Lac]. Student t test and one-way ANOVA followed by Holm-Sidak test (P <0.05) were used to analyze the results. The average HRMÁX was 211 ± 11 and 214 ± 11 bpm for the MB and MP groups, respectively, with no difference (P> 0.05) between them. The [Lac] increased as a result of MET, with no difference between groups. This indicated that horses of both groups had the same physical fitness levels. The OMT stages defined in our study differed regarding the relative intensity o... (Complete abstract click electronic access below)
Mestre

Myocardial and skeletal muscle high energy phosphate metabolism is abnormal in heart failure, but the pathophysiology is not understood. Plasma non-esterified fatty acids (NEFA) increase in heart failure due to increased sympathetic drive, and regulate the transcription of mitochondrial uncoupling protein-3 (UCP3), through peroxisome proliferator-activated receptor-α. The aim of the work in this thesis was to determine whether cardiac PCr/ATP ratios and skeletal muscle PCr kinetics during exercise were related to cardiac and skeletal muscle UCP3 levels respectively, thus providing a mechanism for the apparent mitochondrial dysfunction observed in heart failure. Patients having cardiac surgery underwent pre-operative testing, including cardiac and gastrocnemius 31P magnetic resonance spectroscopy. Intra-operatively, ventricular, atrial and skeletal muscle biopsies were taken for measurement of mitochondrial protein levels by immunoblotting, along with mitochondrial function by tissue respiration rates. Fasting plasma NEFA concentrations increased in patients with ventricular dysfunction and with New York Heart Association (NYHA) class. Ventricular UCP3 levels increased and cardiac PCr/ATP decreased with NYHA class, however, demonstrated no relationship to each other. In skeletal muscle, maximal rates of oxidative ATP synthesis (Qmax) related to functional capacity. Skeletal muscle UCP3 levels increased with NYHA class but were unrelated to skeletal muscle Qmax. Tissue respiration experiments revealed no relationship between ventricular function and indices of mitochondrial coupling, furthermore, indices of mitochondrial coupling were unrelated to tissue UCP3 levels. No evidence was found to support mitochondrial uncoupling, mediated through UCP3, as a cause of the abnormalities in cardiac and skeletal muscle high energy phosphate metabolism.

The Bolivian Ornate Tinamou, Nothoprocta ornata, lives higher than 3300 m above sea level and must constantly deal with a restricted availability of atmospheric oxygen, i.e., chronic hypoxia. Interestingly enough, the Ornate Tinamou has a small heart to body ratio, which implies a reduced ability in transporting oxygenated blood to the tissues. In order to increase knowledge about the cardiorespiratory response of the Ornate Tinamou, heart rate (HR) and ventilation frequency (VR) were monitored during resting at 25 °C. The values were compared with those obtained in conditions known to elevate metabolism, i.e., lowered temperature and graded exercise. This was later compared with domestic chickens, Gallus gallus. Results showed a significant increase in HR at 4 °C, 305 ±42 bpm in the Ornate Tinamou when compared with HR at 25°C, 241± 48 bpm (330 ±42bpm and 239 ±32bpm in chicken). A significant increase in VR was only observed in chicken. As expected, with a progressive increase in running speed, a significant increase in HR in both species was observed. At 1,5 km h-1, HR in the Ornate Tinamou was 327 ±5,6 bpm and 342 ±8,5 in chicken. At 3,0 km h -1 HR was 383 ±15 bpm and 404 ±7,9, respectively. However, HR was not significantly higher in the Ornate Tinamou than in chicken, indicating that there must be other physiological adaptations involved in the sufficient oxygen delivery to tissues, e.g. a high blood oxygen affinity or a preference for anaerobic metabolism due to living in a chronic hypoxic environment.

Iron is one of the essential elements involved in various fundamental biological activities. However, excess iron may bypass the negative feedback regulatory systems, leading to the formation of iron overload. The increase of iron deposition generates cellular toxicity and subsequently damages vital organs. Primary and secondary iron overload are affecting patients worldwide. Iron overload cardiomyopathy is the primary cause of cardiac dysfunction and cardiovascular mortality in β-thalassaemia major patients. Current effective therapy includes chelation treatment with conventional and new iron chelators, while potential new therapies are currently under development. The pathophysiology of iron overload cardiomyopathy remains unclear. Controversial findings on the mechanism of excessive iron entry into cardiomyocytes exist. Using novel real-time approach to trace iron entry into HL-1 cardiomyocytes, the only beating cardiac cell line with mature cardiac phenotype available currently, we visualized the patterns of iron entry following ferric iron incubation with and without ascorbate. Iron entry could be partly blocked by pretreatment with L-type calcium channel blockers but not T-type calcium channel blocker. Such blockage effect by L-type calcium channel blockers occurred in ferric iron overload. This finding suggested a role of L-type calcium channels for ferric iron uptake into cardiomyocytes under iron overload condition. For the pathophysiology of iron cardiac toxicity, we assessed the iron overload induced apoptosis using both in vitro and in vivo approaches. The results demonstrated that iron-overloaded mouse HL-1 atrial cardiomyocytes and human embryonic stem cell derived ventricular cardiomyocytes underwent apoptosis via the mitochondria-mediated caspase-3 dependent pathway. Supportive data was found in iron-overloaded mouse myocardium by an increase in DNA fragmentation. However, despite the blockage of iron entry, L-type calcium channel blockers did not significantly prevent iron induced apoptosis in vitro. The mechanism of cardiac contractile dysfunction caused by iron overload on cardiomyopathy has not yet been fully characterized. Given the central role of titin, the giant myofilament protein, as the main determinant in myocardial passive tension, stiffness, diastolic and systolic cardiac function, as well as myocardial twisting and untwisting motion, we investigated its expression in iron-overloaded cardiomyocytes in vitro and in vivo. Our results indicated that significant degradation of cardiomyocytes titin was induced by iron overload. This was associated with the cleavage at the elastic domain. Its potential upstream protease, calpain, was further identified to be activated under iron overload. The specific role of titin proteolysis in iron-overloaded cardiomyocytes merited further investigation. The findings in this project provided new insights to the pathophysiology of iron overload cardiomyopathy, in terms of the route for iron entry, iron induced cardiac apoptosis, and titin proteolysis. Novel therapeutic approaches for prevention and treatment of iron overload cardiomyopathy can focus on inhibiting excessive iron uptake, as well as by targeting pathways involved in cardiac apoptosis and titin proteolysis.
published_or_final_version
Paediatrics and Adolescent Medicine
Doctoral
Doctor of Philosophy

Thesis (MSc)--Stellenbosch University, 2008.
ENGLISH ABSTRACT: Gene expression of the cardiac isoform of acetyl-CoA carboxylase (ACCb) is induced in a glucose-dependent manner. ACCb produces malonyl-CoA, a potent inhibitor of mitochondrial fatty acid uptake. Previous studies show that increased flux through the hexosamine biosynthetic pathway (HBP) under hyperglycaemic conditions may contribute to the development of insulin resistance. In light of this, we hypothesised that increased HBP flux induces cardiac ACCb gene expression thereby contributing to the onset of insulin resistance. We tested our hypothesis by transiently transfecting cardiac-derived rat H9c2 myoblasts with a 1,317 bp human ACCb promoter-luciferase construct (pPIIb-1317) and an expression construct encoding the rate-limiting step of the HBP i.e. glutamine: fructose 6-phosphate amidotransferase (GFAT). Overexpression of GFAT increased ACCb gene promoter activity by 75 ± 23% versus controls (n=6, p<0.001). When cotransfection experiments were repeated in the presence of varying concentrations of L-glutamine (0 mM, 4 mM, 8 mM), a substrate for the HBP, ACCb promoter activity was dose-dependently increased. To further corroborate these findings, we employed two inhibitors of GFAT, i.e. 40 μM azaserine and 40 μM 6-diazo-5-oxo-Lnorleucine were administered to transfected cells for a period of 24 hours. Here both azaserine and 6-diazo-5-oxonorleucine attenuated ACCb gene promoter activity. In agreement, co-transfections with two dominant negative GFAT constructs also diminished ACCb gene promoter activity. We next inhibited two enzymes of the HBP acting downstream of GFAT, i.e. O-GlcNAc transferase and O-GlcNAcase using alloxan (0.1 mM, 1 mM and 2 mM) and streptozotocin (5 mM and 10 mM), respectively, for a period of 24 hours. Addition of alloxan attenuated ACCb gene promoter activity by 35.6 ± 1.9% (n=16, p<0.001) and streptozotocin increased activity by 32 ± 12% (n=12, p<0.001). We also investigated USF1 and USF2 as transcriptional regulatory candidates for HBP-induced ACCβ promoter regulation. Our data implicates USF2 as an important transcriptional regulator of HBP-induced ACCβ promoter regulation. In summary, this study demonstrates that increased flux through the hexosamine biosynthetic pathway induces ACCb gene promoter activity. We further propose that such an induction would reduce cardiac fatty acid oxidation, thereby leading to intracellular lipid accumulation due to a mismatch between sarcolemmal FA uptake and mitochondrial FA oxidation in the insulin resistant setting (i.e. hyperlipidaemia).
AFRIKAANSE OPSOMMING: Geen uitdrukking van die kardiale isoform asetiel-KoA karboksilase (ACCb) word in ‘n glukose afhanklike wyse geïnduseer. ACCb produseer maloniel-KoA, ‘n kragtige inhibeerder van mitochondriale vetsuuropname. Vorige studies toon aan dat verhoogde fluks deur die heksosamien biosintestiese weg (HBW) onder hiperglukemiese toestande bydra tot die ontwikkeling van insulienweerstand. In die lig hiervan, word daar gehipotetiseer dat verhoogde HBP fluks kardiale ACCb geenuitdrukking induseer en so bydra tot die ontstaan van insulienweerstand. Ons hipotese is getoets deur die kardiale afkomstige rot H9c2 mioblaste met ‘n 1.317 bp mens ACCb-lusiferase promotor konstruk (pPII-1317) te transfekteer en ‘n uitdrukking te konstrueer wat die tempo bepalende stap van HBP i.e. glutamien: fruktose-6-fosfaat amidotransferase (GFAT) kodeer. Ooruitdrukking van GFAT verhoog ACCb geenpromotor aktiviteit deur 75 ± 23% teenoor kontrole (n=6, p<0.001). Die herhaling van ko-transfeksie eksperimente is herhaal in die teenwoordigheid van variëerbare L-glutamienkonsentrasies (0 mM, 4 mM, 8 mM), ’n substraat vir die HBP, ACCb promotor aktiwiteit is dosisafhanglik verhoog. Om die bevindinge verder te staaf, is twee inhibeerders van GFAT, i.e. 40 μM azaserien en 40 μM 6-diazo-5-oxo-L-norleusien aan transfeksie selle toegedien vir ’n tydperk van 24 uur. Beide azaserien en 6-diazo-5-oxo-L-norleusien verlaag ACCb geenpromotor aktiwiteit. In ooreenstemming met die bogenoemde het ko-transfeksies met twee dominante negatiewe GFAT konstrukte ook ACCb geenpromoter aktiwiteit verminder. Die volgende stap is om twee ensieme van die HBP wat stroomaf van GFAT aktief is, vir ‘n periode van 24 uur te inhibeer i.e. O-GlcNAc transferase en O-GlcNAcase deur alloxan (0.1 mM, 1 mM en 2 mM) and streptozotosien (5 mM en 10 mM) onderskeidelik vir ‘n 24 uur periode te gebruik. Toevoeging van alloxan het die ACCb geenpromotor aktiwiteit by 35.6 ± 1.9% (n=16, p<0.001) verlaag en streptozotosien aktiwiteit verhoog by 32 ± 12% (n=12, p<0.001). Ons het ook die USF1 en USF2 as transkripsie regulerings kandidate vir HBP-geïnduseerde ACCβ promotor regulering ondersoek. Ons data impliseer dat USF2 as ‘n belangrike transkripsie reguleerder van HBP-geïndiseerde ACCβ promotor regulering is. Samevattend het hierdie studie demonstreer dat verhoogde fluks deur die hexosamien biosintetiese weg ACCb geenpromotor aktiwiteit induseer. Ons stel verder voor dat hierdie induksie die kardiale vetsuuroksidasie verlaag wat daartoe lei dat intrasellulêre lipied akkumulasie as gevolg van onparing tussen sarkolemma vetsuuropname en mitochondriale vetsuuroksidasie in ’n insulien weerstandige situasie (i.e. hiperlipidaemia).

Changes in myocardial energetics have been implicated in the pathophysiology of heart failure (HF). However, the precise contribution of creatine (Cr) / phosphocreatine (PCr) / creatine kinase (CK) energy buffer and transfer remains unclear. The aim of this thesis was to study the effects on murine cardiac function of both impairment and enhancement of creatine metabolism. In order to longitudinally follow the cause and effect relationship of myocardial creatine concentration, a non-invasive method of quantification was required. Cardiac Cr levels measured in vivo by 1H-MRS were therefore compared with gold-standard invasive HPLC and found to correlate over a wide-range (r2=0.91). 1H-MRS was reproducible for measuring Cr levels in the heart, brain, and skeletal muscle. The cardiac phenotype of a novel model of creatine depletion, the AGAT-/- mouse, was characterized using in vivo MRI, 1H-MRS and LV catheterisation, under conditions of gradually reducing Cr concentrations; zero Cr; and attempted phenotype rescue with dietary Cr. For the first time in the heart, the rate of Cr turnover was quantified (~3 % per day) and demonstrated that cardiac function was preserved even when creatine levels reduced by ~70-90%. Total absence of myocardial Cr induced impairment of inotropic and lusitropic cardiac function and reduced inotropic reserve. Cardiac dysfunction was only partially rescued by replenishment of the Cr pool, suggesting this to be a consequence of long-term adaptations to chronic low Cr. Finally, we tested the hypothesis that combined elevation of myocardial creatine and ribose would be beneficial in a mouse model of chronic HF by increasing cardiac energy availability. Despite an increase in myocardial ribose concentration, this did not prevent loss of total adenine nucleotides (TAN), and there was no improvement in post-infarct LV remodeling or function. Future studies are needed to explore alternative approaches for maintaining TAN in combination with total creatine.

It has been suggested that a failure of angiogenesis (capillary growth) to keep pace with myocyte expansion is the driving force which pushes hypertrophied hearts into a state of failure marked by contractile dysfunction and alterations in the mechanisms governing energy production. The aims of this study were to investigate how alterations in ventricular capillarity affect contractile performance and substrate metabolism in the isolated rat heart. It was hypothesised that, if cardiac contractile performance and substrate utilisation are directly related to ventricular capillarity then methods to alter the number and distribution of capillaries within the ventricle could be utilised to demonstrate this relationship. Treatment regimes were split into those aimed at inducing new capillary growth (e.g. chronic bradycardia and exposure to cold environments) and those aimed at reducing ventricular capillarity (e.g. hypertension and beta-adrenoceptor stimulation). In contrast to previous reports, capillary growth within the ventricle was very limited in animals exposed to a chronic increase in energy demand (e.g. cold environments) and those subjected to extended periods of mechanical stimulation (e.g. bradycardia). Ventricular remodeling appears to accommodate for alterations in the load and/or energy demand without the need for an expansion of the existing capillary network. Experiments conducted in beta-adrenoceptor mediated hypertrophy demonstrate that capillary rarefaction has little effect on cardiac contractile performance and experiments with hypertensive animals show no capillary growth despite the dramatic increase in energy demand placed on the heart in these conditions. In conclusion these data demonstrate surprising plasticity in the response of the myocardium to a number of physiological and pathological stimuli and indicate that adequate compensation occurs without the need for expansion of the existing capillary bed. The limited angiongenic capacity of the myocardium may therefore indicate that the capillary supply of the ventricle is not limiting to the function of the heart.

The concept that high plasma concentrations of high density lipoproteins (HDL) offers protection against coronary heart disease has been challenged on epidemiological grounds. This dispute may arise as a result of the heterogeneous nature of HDL in which only some subspecies exert a protective function while the major portion has a neutral role. In order to test this hypothesis, the distribution of HDL subfractions in 100 myocardial infarction (MI) survivors was examined within 12 hours of the onset of chest pain and before post-MI changes in lipoproteins occurred. These patients were shown to have a significantly lower percentage distribution of apoprotein E-rich HDL measured by heparin-Sepharose affinity chromatography, and of HDL2b estimated by gradient gel electrophoresis, yet a higher percentage distribution of HDL3c than a similarly sized group of healthy control subjects. At six months post-MI follow-up with an appropriate improvement in lifestyle, as well as therapeutic treatment, there was a significant increase in the percentage distribution of apoprotein E-rich HDL and of HDL2b and a significant decrease in HDL3c, with no alteration in total HDL or any other lipoprotein component. Measurement of these HDL subfractions may thus provide a better indicator of coronary risk than of total plasma cholesterol, which is frequently employed for this purpose, but was found indistinguishable between the two groups in the present study. Such subfractions also provide useful information into the underlying causes of atherosclerosis. The apoprotein E-rich subfraction of HDL which was shown to be reduced in MI survivors, was further separated into several, more discrete subfractions by heparin-Sepharose affinity chromatography, using a judicious choice of eluting solvents. The separated subfractions differed in mean particle diameter and in lipid and apoprotein composition. The fraction designated HDL2b was shown to comprise three main species which may serve different roles in coronary protection.

The research in this thesis investigated the role of the hypoxia-inducible factor (HIF) family of transcription factors in metabolism and cardiopulmonary physiology. Specifically, the effects of HIF on ventilatory control, carotid body morphology, and cardiac metabolism and function were studied using a murine model of a genetic disorder of oxygen sensing known as Chuvash polycythaemia. HIF coordinates oxygen-regulated gene expression throughout all organ systems, thereby orchestrating cellular, tissue and systemic responses to hypoxia. HIF is primarily regulated by oxygen-dependent prolyl hydroxylase-domain enzymes (PHDs) that initiate its degradation via the von Hippel-Lindau protein (VHL). In Chuvash polycythaemia, a homozygous VHL mutation in humans causes generalised stabilisation of HIF in euoxia, resulting in profound changes in cardiopulmonary physiology, exercise and metabolism. The Chuvash mouse model provides an opportunity to further characterise the role of HIF in different organ systems. Chapter 2 of this thesis introduces the murine model, demonstrating an increase in haemoglobin and haematocrit in the Chuvash mice as well as a marked reduction in body weight. Chapter 3 describes the ventilatory and carotid body study. Chuvash mice were shown to have elevated baseline ventilation in euoxia and marked ventilatory sensitivity to hypoxia. These findings were accompanied by changes within the carotid body, including hyperplasia, hypertrophy and altered ultrastructure of the oxygen-sensing type I cells. Chapter 4 of this thesis describes the study into cardiac metabolism, energetics and function. Chuvash hearts were found to have increased glycolytic flux and lactate production (the latter both in and ex vivo), with altered myocardial energetics. Despite this, left ventricular function remained normal, although in vivo cine MRI revealed clear evidence of pulmonary hypertension and right ventricular hypertrophy. Overall, this thesis provides evidence that the PHD-VHL-HIF axis plays a major role in calibrating the hypoxic response in the principal organ systems responsible for oxygen uptake, delivery and utilisation.

In utero undernutrition is associated with increased risk for insulin resistance, obesity, and cardiovascular disease during adult life. A common phenotype associated with low birth weight is reduced skeletal muscle mass. Given the central role of skeletal muscle in whole body metabolism, we hypothesized that predisposition to metabolic disease is, in part, due to low oxidative capacity and dysfunctional mitochondrial energetics in muscle. We used an experimental mouse model system of maternal undernutrition during late pregnancy to examine female offspring from undernourished dams (U) and control offspring from ad libitum fed dams (C). U have increased adiposity and decreased glucose tolerance compared to C. Strikingly, when U are put on a 4 week 40% calorie restricted diet they lose half as much weight as calorie restricted controls. Skeletal muscle mitochondria from U have decreased coupled and uncoupled respiration and increased maximal respiration compared to C. In permeabilized fiber preparations from mixed fiber type muscle, U have decreased mitochondrial content and decreased adenylate free leak respiration, fatty acid oxidative capacity, and state 3 respiratory capacity through complex I. Fiber maximal oxidative phosphorylation capacity does not differ between U and C. We next aimed to determine if the impaired skeletal muscle energetics observed in U also exist in primary muscle cells derived from these mice. We measured oxidative and glycolytic capacities in primary myotubes from U and C using cellular bioenergetics. Myotubes from U have decreased resting respiration and increased glycolysis compared to myotubes from C. There was no difference in myotube mitochondrial content. Findings suggest that undernutrition in utero causes a primary muscle defect. Energetics in cardiac muscle were also examined. U have impaired cardiac muscle homogenate energetics, including decreased fatty acid oxidative capacity, decreased maximum oxidative phosphorylation rate, and decreased proton leak respiration. Additionally, we measured plasma acylcarnitine levels and found that short-chain acylcarnitines are increased in U. Overall, results reveal that in utero undernutrition alters metabolic physiology through a profound effect on skeletal muscle and cardiac muscle energetics. These effects may be mediated by epigenetic mechanisms which could be explored in future research.

The aim of this thesis was to develop and apply new hyperpolarized magnetic resonance spectroscopy techniques, to assess in vivo metabolism in the rodent heart. Initial work using rat models of heart disease has provided key findings, such as significant increases in pyruvate dehydrogenase flux in the hypertensive rat heart and metabolic alterations in the TCA cycle during the progression into heart failure. Both could provide future non-invasive markers for the metabolic alterations associated with hypertrophy and heart failure in patients. Whilst both of these models provided useful information regarding the metabolic abnormalities of the diseased heart there is also a need to better characterize the individual metabolic pathways that are modified during heart disease. This requires the study of genetically modified animals, namely transgenic mouse models. However, the translation of the hyperpolarized technique from rat to mouse is particularly challenging, mainly due to the mouse heart being a tenth of the size of the rat heart and with a heart rate at least twice as fast. Work in this thesis details the development of mouse cardiac dynamic nuclear polarization (DNP). The development of this technique allowed interesting insights in to differences in the in vivo metabolic phenotype of commonly used “control” mouse strains, and of mouse models of defects associated with β-oxidation. This work also demonstrated that hyperpolarized [1-¹³C]pyruvate could be used to monitor anaplerotic pathways in the stressed mouse heart, potentially increasing its power for clinical use. In combination with cine-MRI and ³¹P MRS, this work has highlighted that DNP could play an important role in the diagnosis and prognosis of cardiovascular diseases.

Amendments inserted at back. "May 2002" Includes bibliographical references (leaves 237-290) Experiments described in this thesis address the potential role of inducible nitric oxide synthase (iNOS) in hibernating myocardium. Specifically it was sought to establish a cellular model of hibernating myocardium and investigate the expression, regulation and effects of iNOS in this model. Experiments were performed using primary cultures of neonatal rat ventricular myocytes.

[Formulae and special characters can only be approximated here. Please see the pdf version of the abstract for an accurate reproduction.] Atherosclerosis is a common degenerative disease in which the clinical manifestations are often through stroke or myocardial infarction. Some of the established risk factors for atherosclerosis include elevated plasma low-density lipoprotein (LDL)-cholesterol levels, obesity, diabetes mellitus (DM) and cigarette smoking. Of the risk factors, an elevation in plasma LDL is one of the most established and the most researched. This is partly a consequence of the deposition of cholesterol within arterial intima being a crucial step in the progression of atherosclerosis, combined with the finding that LDL particles are a major transporter of cholesterol in circulation. Recently there is increasing evidence showing a role of the other major transporter of cholesterol in circulation, chylomicron remnants, in the progression of atherosclerosis. The notion of atherosclerosis as a postprandial phenomenon has been further substantiated by the emergence of evidence showing a direct role of chylomicron remnants in arterial cholesterol deposition. Based on evidence that chylomicron remnants are proatherogenic, the suggestion arises that accumulation of postprandial lipoproteins in plasma may add another dimension of risk to the development of coronary artery disease (CAD). This thesis tests the general hypothesis that individuals with or at high risk of CAD have postprandial dyslipidaemia and that this metabolic abnormality is correctable with a class of lipid-lowering drugs called statins. To test the hypothesis, clinical studies were conducted in normolipidaemic CAD patients, heterozygous familial hypercholesterolaemia (FH) and postmenopausal women with type 2 DM. Determination of postprandial dyslipidaemia by comparison with control populations were conducted initially in each patient group (Studies 1, 3 and 5), followed by intervention studies investigating possible modulation of the dyslipidaemia with a statin (Studies 2, 4 and 6). Six observation statements based on case-control comparisons of postprandial lipaemia in patients with or at risk of CAD and the effects of statins on postprandial dyslipidaemia in the patient groups were derived from the general hypothesis. The observation statements were examined in the individual studies described below. Postprandial lipoprotein metabolism was assessed using a number of methods. For comparison of postprandial lipaemia in Studies 1 and 2, a classic oral fat challenge was utilised. As markers of chylomicrons and chylomicron remnants, retinyl palmitate and triglyceride were measured postprandially as well as apolipoprotein (apo) B48 concentrations, a specific marker of intestinal lipoproteins. ApoB48 was also measured in the fasting state and found to predict the postprandial responses of retinyl palmitate, triglyceride and apoB48. This suggested that fasting measurement of apoB48 could be used as a simple indicator of postprandial dyslipidaemia. Consequently for Studies 3 - 6, fasting apoB48 measurements were used as primary markers of postprandial dyslipidaemia. Other markers for chylomicrons and their remnants utilised were fasting plasma concentrations of remnant-like particle-cholesterol (RLP-C) and apoC-III. As well as these static markers, chylomicron remnant catabolism was measured using a stable isotope breath test. The breath test involves the intravenous injection of a chylomicron remnant-like emulsion labelled with ¹³C-oleate and measurement of enriched ¹³CO2 in expired breath by isotope ratio mass spectrometry. The fractional catabolic rate (FCR) of the injected emulsion was subsequently calculated using multi-compartmental modeling (SAAM II). The studies are presented in this thesis as published and unpublished works. In Study 1, postprandial lipoprotein metabolism was compared between 18 normolipidaemic CAD patients (cholesterol 4.54 ± 0.12 mmol/L, triglyceride 1.09 ± 0.16) with 13 asymptomatic healthy controls using an oral fat challenge. Normolipidaemic CAD patients had higher postprandial area-under-curve (AUC) for triglyceride (+34%, p=0.019), retinyl palmitate (+74%, p=0.032) and apoB48 (+36%, p<0.001). Fasting apoB48 was also higher (+41%, p=0.001) and found to correlate significantly with AUC of triglyceride (p=0.017), retinyl palmitate (p=0.001) and apoB48 (p<0.001). The data suggest that normolipidaemic CAD patients have increased concentrations of intestinal lipoproteins in the fasting and postprandial state. In addition to these findings, significant correlations of fasting apoB48 with postprandial markers (p<0.02) suggests the fasting marker to be a simpler surrogate marker for the degree of total postprandial lipaemia. Study 2 investigated the effect of atorvastatin treatment on postprandial dyslipidaemia found in the 18 near-normolipidaemic CAD patients from Study 1. The trial was conducted in a randomised, placebo-controlled design, using oral fat challenges before and after 12-weeks atorvastatin/placebo treatment. Compared with the placebo group, atorvastatin decreased the total postprandial AUC for iii triglyceride (-22%, p=0.05) and apoB48 (-34%, p=0.013). Fasting markers of apoB48 (-35%, p=0.019) and RLP-C (-36%, p=0.032) also decreased significantly. Atorvastatin was also found to increase LDL-receptor activity by +218% (p<0.001) as reflected in binding studies. The data suggest atorvastatin reduces the fasting levels of intestinal lipoproteins as well as total postprandial lipaemia, but without acute dynamic changes in postprandial lipaemia. The reduction in fasting and total postprandial lipoprotein levels could be partly attributed to an increase in LDL-receptor mediated removal from circulation. In Study 3, postprandial lipaemia was compared in 15 heterozygous FH patients with 15 healthy controls. FH patients had higher fasting concentrations of apoB48 (+56%, p<0.001) and RLP-C (+48%, p=0.003). The elevation in these fasting markers of chylomicrons and their remnants suggests FH patients have postprandial dyslipidaemia due to an accumulation of these particles in plasma. Study 4 examined the effects of long- (> 6 months) and short-term (4 weeks) simvastatin treatment on modulating postprandial dyslipidaemia found in the 15 FH patients from Study 3. Short- and long-term simvastatin treatment decreased the fasting concentrations of apoB48 (-29% and 15% respectively, p<0.05) and RLP-C (both -38%, p<0.001), but did not significantly alter the FCR of the injected chylomicron remnant-like emulsion. The data suggest that in heterozygous FH both long- and short-term simvastatin treatments decrease the fasting markers of postprandial lipoproteins by mechanisms that may not be mediated via processes differentiated by the 13CO2 breath test. This implies that the effect on postprandial lipaemia may be from a decrease in production and/or a possible increase in catabolism of triglyceride-rich lipoproteins (TRLs). In Study 5, postprandial lipaemia was compared in 24 postmenopausal women age and body mass index matched with 14 postmenopausal women with type 2 DM. Postmenopausal diabetic women were found to have higher fasting concentrations of apoB48 (+21%, p=0.021) and apoC-III (+16%, p=0.042) as well as lower FCR of the chylomicron remnant-like emulsion (-50%, p<0.001). The data suggest that postmenopausal diabetic women have postprandial dyslipidaemia, and that this is due to delayed catabolism of chylomicron remnants. Study 6 was an hypothesis-generating exercise examining the effects of 4-weeks pravastatin treatment on postprandial dyslipidaemia found in 7 postmenopausal women with type 2 DM from Study 5. Although plasma LDL-cholesterol was reduced (-19%, p=0.028), there were no significant effects found on fasting apoB48 concentrations (-12%, p=0.116) or the FCR of the chylomicron remnant-like emulsion (+38%, p=0.345). A larger sample size of patients and/or treatment with a more potent statin at a dosage known to affect chylomicron remnant metabolism would be required to demonstrate a significant reduction in postprandial dyslipidaemia in postmenopausal women with type 2 DM. The results of the above mentioned studies combined support the general hypothesis that postprandial dyslipidaemia is a feature of patients with or at risk of CAD. This defect may be demonstrated using fasting apoB48 as an indicator of the degree of postprandial lipaemia. Postprandial dyslipidaemia may reflect a reduction in catabolism, as suggested with the breath test in type 2 DM, and/or an over overproduction of chylomicrons. Both these mechanisms would also increase competition for lipolysis and clearance pathways between hepatically and intestinally-derived lipoproteins. The exact mechanisms by which postprandial dyslipidaemia occurs are yet to be determined. Statins appear to improve defective postprandial lipaemia in patients with or at risk of CAD, which is in agreement with the general hypothesis. The effectiveness of a statin is dependant on their potency in inhibiting cholesterol biosynthesis and increasing receptor mediated clearance of LDL and chylomicron remnants. The studies conducted in this thesis show that postprandial dyslipidaemia can be reduced by statins but not to the extent demonstrated in controls. However, the demonstrated reduction in fasting and total postprandial lipaemia translates to a lowering in overall arterial exposure to circulating proatherogenic particles. The elevation in fasting and postprandial levels of proatherogenic chylomicron remnants found in the patient groups described in this thesis indicates another dimension to their risk of coronary disease. The reductions in the overall levels of proatherogenic particles in patients with or at high CAD risk, infers a possible reduction in the risk of coronary disease in these patients.

Postoperative heart failure (PHF) remains a major determinant of the outcome after cardiac surgery. However, characteristics of and risk factors for PHF after valve surgery have received little attention. Post-ischaemic disturbances of myocardial metabolism that may contribute to PHF and are amenable to metabolic treatment have been identified early after coronary surgery (CABG). Knowledge derived from these studies may not be applicable to other patient groups. We therefore studied myocardial energy metabolism in 20 elective patients undergoing aortic valve replacement (AVR) for isolated aortic stenosis (AS). The metabolic studies indicated that myocardial oxidative metabolism had not fully recovered when the procedure was completed. Free fatty acids were the only major substrates taken up by the heart. Signs of preoperative and postoperative metabolic adaptation with substantial uptake of glutamate, previously demonstrated in patients with coronary artery disease, were found. Postoperative infusion of glutamate, (2 mL/kg body weight and hour of 0.125 M solution) based on assessment of myocardial glutamate requirements in CABG patients, resulted in a two-fold increase in myocardial glutamate uptake and a seven-fold increase in AV differences across the leg. This was associated with a significant myocardial uptake of lactate and metabolic changes in the leg suggesting mitigation of net amino acid loss and peripheral tissue lipolysis. Characteristics of and risk factors for PHF were evaluated in 398 patients undergoing isolated AVR for AS from 1 January 1995 to 31 December 2000. These were compared with 398 patients, matched for age and sex, undergoing on-pump isolated CABG. Forty-five AVR and 47 CABG patients fulfilled criteria for PHF and these were studied in detail. PHF usually presented at weaning from cardiopulmonary bypass. After CABG it was closely associated with preoperative ischaemic events and intraoperatively acquired myocardial infarction. Potential causes and eliciting events of PHF after AVR for AS were obvious only in one-third of the patients. Risk factors for PHF after AVR for AS indicated either pre-existing myocardial dysfunction, increased right or left ventricular after-load, or intraoperatively acquired myocardial injury. PHF was associated with high early mortality after CABG, whereas the consequences of PHF after AVR for AS became evident only with time, resulting in a 42% five-year mortality. Although PHF had a different temporal impact on late mortality after CABG and AVR for AS, it emerged as the statistically most significant risk factor for mortality occurring within 5 years from surgery both after AVR for AS and after CABG. Potential implications of our findings include needs for greater focus on preoperative surveillance of patients with AS for optimal timing of surgery, mitigation of intraoperatively acquired myocardial injury and tailoring of treatment for PHF. Furthermore, the findings have implications for long-term follow up of AS patients after surgery.

Both hypertrophied and failing hearts are characterised by pathological left ventricular (LV) remodelling, impaired myocardial energy status and alteration in substrate metabolism. Cardiac magnetic resonance imaging (CMR) and magnetic resonance spectroscopy (MRS) are powerful tools in the characterisation of these disease conditions. More recent techniques have allowed assessment of myocardial steatosis using ¹H-MRS and tissue oxygenation using blood oxygen level dependent (BOLD) CMR. In hypertrophy and heart failure, studies on steatosis and the relationship with other parameters such as myocardial function and fibrosis, especially in humans are limited. I therefore investigated the presence of steatosis in severe aortic stenosis (AS) and dilated cardiomyopathy (DCM), and further assessed its relation to contractile function. This study found that myocardial triglyceride (TG) content is increased in both symptomatic and asymptomatic AS patients (lipid/water ratio 0.89±0.42% in symptomatic AS; 0.75±0.36% in asymptomatic AS vs. controls 0.45±0.17%, both p<0.05) and DCM patients (lipid/ratio 0.64±0.44% vs. controls 0.40±0.13%, p=0.03). Circumferential strain was lower in both AS (-16.4±2.5% in symptomatic AS; -18.9±2.9% in asymptomatic AS vs. controls 20.7±2.0%, both p<0.05) and DCM patients (-12.3±3.4% vs. controls -20.9±1.7%, p<0.001). In AS, myocardial contractility is related to the degree of steatosis, and were both reversible following aortic valve replacement (AVR), lipid/water ratio 0.92±0.41% vs. pre AVR 0.45±0.17%, p=0.04 and circumferential strain -17.2±2.0% vs. pre AVR -19.5±3.2%, p=0.04. A novel finding of this study was significant correlation of MRS-measured TG content with histological staining of TG of the myocardium, taken from endomyocardial biopsy during AVR. In DCM, myocardial TG was independently associated with LV dilatation and correlated significantly with hepatic TG, which suggests that both cardiac and hepatic steatosis might be a common feature in the failing heart. Additionally, although the hypertrophied heart is characterised by impaired perfusion, it is unknown if this is severe enough to translate into tissue deoxygenation and ischaemia. I assessed this by using adenosine vasodilator stress test and BOLD-CMR in patients with severe AS. It was found that AS patients had reduced perfusion (myocardial perfusion reserve index-MPRI 1.0±0.3 vs. controls 1.7±0.3, p<0.001), and blunted tissue oxygenation (blood-oxygen level dependent-BOLD signal intensity-SI change 4.8±9.6% vs. controls 18.2±11.6%, p=0.001) during stress. Importantly, there was a substantial improvement in perfusion and oxygenation towards normal after AVR, MPRI 1.5±0.4, p=0.005 vs. pre AVR and BOLD SI change 16.4±7.0%, p=0.014 vs. pre AVR. Overall, the work in this thesis supports the powerful role of CMR in assessing LV function and elucidating metabolic mechanisms in the hypertrophied and failing heart.