The impact of obesity on heart failure.

PURPOSE OF REVIEW: Obesity, a growing global health problem, contributes to the development of heart failure. However, increased BMI seems protective for those with established disease, a phenomenon known as the 'obesity paradox'. In this review, we outline the mechanism through which obesity can contribute to the development of heart failure, explore the concept of obesity paradox, and highlight the challenges that obesity presents for advanced heart failure therapy. RECENT FINDINGS: Although the mechanism underlying the obesity paradox is complex, meta-analysis shows that intentional weight loss through bariatric surgery can indeed improve cardiac structure and function. With regard to ventricular assist device therapy in obese patients, recent studies demonstrate that while obesity was indeed associated with higher likelihood of complications, there were no statistically significant differences in terms of mortality or delisting from cardiac transplant waiting list. SUMMARY: Obesity is strongly associated with the development of heart failure, through direct and indirect mechanisms. Although clear consensus regarding weight reduction in this patient population is lacking, there is mounting clinical evidence that intentional weight loss may be beneficial, in spite of the well-recognized obesity paradox, particularly as the presence of obesity presents unique challenges in the advanced therapy of heart failure patients.

Heart failure and sleep-disordered breathing.

PURPOSE OF REVIEW: Sleep-disordered breathing, which includes both obstructive and central sleep apnoea (OSA and CSA, respectively), is highly prevalent in patients with heart failure. In this review, we outline our current understanding of the bidirectional relationship between these disorders and heart failure. We also explore the role of recent advances in therapeutics. RECENT FINDINGS: Although early studies suggest promise of adaptive servoventilation in treating sleep-disordered breathing, particularly CSA with associated Cheyne-Stokes respiration, the recent clinical trial in the heart failure patient population has demonstrated worse cardiovascular outcome in symptomatic patients. SUMMARY: Both OSA and CSA are highly prevalent in patients with heart failure. Effective treatment of OSA with continuous positive airway pressure can improve cardiovascular outcome in these patients. However, recent evidence suggests that adaptive servoventilation cannot be safely recommended as a therapy for CSA in the context of heart failure, as a result of increased risk of cardiovascular mortality.

Heart rate and heart failure.

PURPOSE OF REVIEW: Resting heart rate has long been thought to be a risk factor in cardiovascular disease and a prognostic factor in heart failure. ß-Blockers were originally used in heart failure for their heart rate control abilities. However, they also have negative inotropic effects contributing to their overall benefit. The role of isolated heart rate modification is unclear in left ventricular systolic dysfunction. RECENT FINDINGS: Two recent studies looked at the heart rate-lowering effects of the If, or funny current inhibitor ivabradine and its potential role in heart failure therapy. At the doses chosen for the studies, ivabradine is presumed to have only effects on heart rate with no other cardiotropic effects. Thus, the cardiovascular outcome benefits are presumed to be secondary to heart rate modification. SUMMARY: The two recent trials showed both heart rate and cardiovascular events to be significantly lower in the ivabradine-treated group of patients with left ventricular systolic dysfunction and initial heart rate at least 70 beats/min. However, neither of these trials proved causality. Hence, the link between heart rate and improved cardiovascular outcomes still remains muddled.

A co-clustering model involving alpha5beta1 integrin for the biological effects of GPI-anchored human carcinoembryonic antigen (CEA).

CEA functions as an intercellular adhesion molecule and is up-regulated in a wide variety of human cancers, including colon, breast and lung. Its over-expression inhibits cellular differentiation, blocks cell polarization, distorts tissue architecture, and inhibits anoikis of many different cell types. Here we report results concerning the molecular mechanism involved in these biological effects, where relatively rapid molecular changes not requiring alterations in gene expression were emphasized. Confocal microscopy experiments showed that antibody-mediated clustering of a deletion mutant of CEA (DeltaNCEA), normally incapable of self binding and clustering, led to the co-localization of integrin alpha5beta1 with patches of DeltaNCEA on the cell surface. Activation of alpha5, as defined by an anti-alpha5 mAb-sensitive increase in cell adhesion to immobilized fibronectin, and an increased binding of soluble fibronectin to cells, was also observed. This was accompanied by the recruitment of integrin-linked kinase (ILK), protein kinase B (PKB/Akt), and the mitogen-activated protein kinase (MAPK) to membrane microdomains and the phosphorylation of Akt and MAPK. Inhibition of PI3-K and ILK, but not MAPK, prevented the alpha5beta1 integrin activation. Conversely, anti-alpha5 antibody inhibited the PI3-K-mediated activation of Akt, implying the involvement of outside-in and inside-out signaling in integrin activation. Therefore we propose that CEA-mediated signaling involves clustering of CEA and co-clustering and activation of the alpha5beta1 and associated specific signaling elements on the internal surfaces of membrane microdomains. These changes may represent a molecular mechanism for the biological effects of CEA.

GPI-anchored CEA family glycoproteins CEA and CEACAM6 mediate their biological effects through enhanced integrin alpha5beta1-fibronectin interaction.

Carcinoembryonic antigen (CEA) and CEA family member CEACAM6 are glycophosphatidyl inositol (GPI)-anchored, intercellular adhesion molecules that are up-regulated in a wide variety of human cancers, including colon, breast, and lung. When over-expressed in a number of cellular systems, these molecules are capable of inhibiting cellular differentiation and anoikis, as well as disrupting cell polarization and tissue architecture, thus increasing tumorigenicity. The present study shows that perturbation of the major fibronectin receptor, integrin alpha5beta1, underlies some of these biological effects. Using confocal microscopy and specific antibodies, CEA and CEACAM6 were demonstrated to co-cluster with integrin alpha5beta1 on the cell surface. The presence of CEA and CEACAM6 was shown to lead to an increase in the binding of the integrin alpha5beta1 receptor to its ligand fibronectin, without changing its cell surface levels, resulting in increased adhesion of CEA/CEACAM6-expressing cells to fibronectin. More tenacious binding of free fibronectin to cells led to enhanced fibronectin matrix assembly and the formation of a polymerized fibronectin "cocoon" around the cells. Disruption of this process with specific monoclonal antibodies against either fibronectin or integrin alpha5beta1 led to the restoration of cellular differentiation and anoikis in CEA/CEACAM6 producing cells.