Proinflammatory phenotype of perivascular adipocytes: influence of high-fat feeding.

Adipose tissue depots originate from distinct precursor cells, are functionally diverse, and modulate disease processes in a depot-specific manner. However, the functional properties of perivascular adipocytes, and their influence on disease of the blood vessel wall, remain to be determined. We show that human coronary perivascular adipocytes exhibit a reduced state of adipocytic differentiation as compared with adipocytes derived from subcutaneous and visceral (perirenal) adipose depots. Secretion of antiinflammatory adiponectin is markedly reduced, whereas that of proinflammatory cytokines interleukin-6, interleukin-8, and monocyte chemoattractant protein-1, is markedly increased in perivascular adipocytes. These depot-specific differences in adipocyte function are demonstrable in both freshly isolated adipose tissues and in vitro-differentiated adipocytes. Murine aortic arch perivascular adipose tissues likewise express lower levels of adipocyte-associated genes as compared with subcutaneous and visceral adipose tissues. Moreover, 2 weeks of high-fat feeding caused further reductions in adipocyte-associated gene expression, while upregulating proinflammatory gene expression, in perivascular adipose tissues. These changes were observed in the absence of macrophage recruitment to the perivascular adipose depot. We conclude that perivascular adipocytes exhibit reduced differentiation and a heightened proinflammatory state, properties that are intrinsic to the adipocytes residing in this depot. Dysfunction of perivascular adipose tissue induced by fat feeding suggests that this unique adipose depot is capable of linking metabolic signals to inflammation in the blood vessel wall.

Enhanced transmural fiber rotation and connexin 43 heterogeneity are associated with an increased upper limit of vulnerability in a transgenic rabbit model of human hypertrophic cardiomyopathy.

Human hypertrophic cardiomyopathy, characterized by cardiac hypertrophy and myocyte disarray, is the most common cause of sudden cardiac death in the young. Hypertrophic cardiomyopathy is often caused by mutations in sarcomeric genes. We sought to determine arrhythmia propensity and underlying mechanisms contributing to arrhythmia in a transgenic (TG) rabbit model (beta-myosin heavy chain-Q403) of human hypertrophic cardiomyopathy. Langendorff-perfused hearts from TG (n=6) and wild-type (WT) rabbits (n=6) were optically mapped. The upper and lower limits of vulnerability, action potential duration (APD) restitution, and conduction velocity were measured. The transmural fiber angle shift was determined using diffusion tensor MRI. The transmural distribution of connexin 43 was quantified with immunohistochemistry. The upper limit of vulnerability was significantly increased in TG versus WT hearts (13.3+/-2.1 versus 7.4+/-2.3 V/cm; P=3.2e(-5)), whereas the lower limits of vulnerability were similar. APD restitution, conduction velocities, and anisotropy were also similar. Left ventricular transmural fiber rotation was significantly higher in TG versus WT hearts (95.6+/-10.9 degrees versus 79.2+/-7.8 degrees; P=0.039). The connexin 43 density was significantly increased in the mid-myocardium of TG hearts compared with WT (5.46+/-2.44% versus 2.68+/-0.77%; P=0.024), and similar densities were observed in the endo- and epicardium. Because a nearly 2-fold increase in upper limit of vulnerability was observed in the TG hearts without significant changes in APD restitution, conduction velocity, or the anisotropy ratio, we conclude that structural remodeling may underlie the elevated upper limit of vulnerability in human hypertrophic cardiomyopathy.

Novel Antidiabetic Therapies and Cardiovascular Risk Reduction: The Role of the Noninferiority Trial.

Diabetes is a major risk factor for cardiovascular disease, yet until now treatments for diabetes had only a modest impact on cardiovascular events. New interventions for patients with type 2 diabetes mellitus (oral empagliflozin and injectable liraglutide) are associated with unprecedented reductions in composite cardiovascular outcomes that seem disproportionate to the impact on glycated hemoglobin. This review examines in detail the recent trials that arrived at these conclusions, limitations of these studies, and how these outcomes may influence patient management in the future.

Systematic review of ß blocker, aspirin, and statin in critically ill patients: importance of severity of illness and cardiac troponin.

Non-cardiac critically ill patients with type II myocardial infarction (MI) have a high risk of mortality. There are no evidence-based interventions to mitigate this risk. We systematically reviewed the literature regarding the use of medications known to reduce mortality in patients with cardiac troponin (cTn) elevation due to type I MI (ß blockers, statin, and aspirin) in studies of critically ill patients without Type I MI. All PubMed publications between 1976-2/19/16 were reviewed. Search terms included: ß blocker or aspirin or statin and intensive care unit (ICU) or critically ill or sepsis; 497 primary references were obtained. Inclusion criteria were as follows: (1) study population consisted of critically ill patients in the ICU with non-cardiovascular illnesses, (2) mortality end point, (3) severity of illness (or injury) was measured, and (4) the antiplatelet agent was primarily aspirin. Retrospective investigations, prospective observational studies, meta-analysis, systematic review, and randomized controlled trials were included; case reports were excluded. 25 primary references were obtained. The data were extracted and tabulated using data collection headings as follows: article title, first author/year/reference number, study type/design, population studied, outcome and intervention, and study question addressed. Evidence was not graded as the majority of studies were non-randomized (low-to-moderate quality). 11 studies were found through bibliography reviews for a total of 36 references. In conclusion, ß blockers, statins, and aspirin may play a role in reducing mortality in non-cardiac critically ill patients. Benefit appears to be related to severity of illness, for which cTn may be a marker.

Three-dimensional anatomy of the conduction system of the early embryonic rabbit heart.

The complete embryonic cardiac conduction system is difficult to view in three dimensions, primarily because there has not been a marker of all segments of the normal system throughout all stages of development. Imaging of the conduction system components within the atria has been particularly controversial because different markers reveal different pathways that may or may not represent conduction system components. The conduction system of the adult and embryonic rabbit, however, can be labeled in its entirety with the neurofilament marker, NF-160. The conduction system of rabbit embryos at several stages of development spanning cardiac septation was therefore investigated. Optical mapping of the electrical signature of the conduction system previously revealed a close correlation between the cardiac activation patterns and the anatomy as shown by serial sections. The 3D relationship between the components of the conduction system could only be inferred from the 2D sections. The sections were consequently reconstructed using a commercial software program (AutoQuant). This is the first demonstration of the three-dimensional complete normal rabbit embryonic cardiac conduction system at several stages of development.

Cardiac Troponin Measurement in the Critically Ill: Potential for Guiding Clinical Management.

BACKGROUND: Elevated cardiac troponin (cTn) in the absence of acute coronary syndromes (ACS) is associated with increased mortality in critically ill patients. There are no evidence-based interventions that reduce mortality in this group. OBJECTIVES: We performed a retrospective investigation of the Veterans Administration Inpatient Evaluation Center database to determine whether drugs used in ACS (ß-blockers, aspirin, and statins) are associated with reduced mortality in critically ill patients. METHODS: Thirty-day mortality was determined for non-ACS patients admitted to any Veterans Administration Intensive Care Unit between October 1, 2007, and September 30, 2008, adjusted for severity of illness. Troponin assay values were normalized across institutions. RESULTS: Multivariate analyses for 30-day mortality showed an odds ratio (OR) of 1.82 for patients with high cTn (P < 0.0001, cTn > 10% coefficient of variation) and 1.18 for intermediate cTn (P = 0.0021, cTn between lowest limit detectable and 10% coefficient of variation) compared with patients with no elevation, adjusting for severity of illness (n = 19,979). Logistic regression models showed that patients with no or intermediate elevations of cTn taking statins within 24 hours of cTn measurement had a lower mortality than patients not taking statins (OR, 0.66; 95% confidence interval [95% CI], 0.53-0.82; P = 0.0003), whereas patients with high cTn had a lower mortality if they were taking ß-blockers or aspirin within 24 hours of cTn measurement compared to patients not taking ß-blockers or aspirin (ß-blockers: OR, 0.80; 95% CI, 0.68-0.94; P = 0.0077; aspirin: OR, 0.81;95% CI, 0.69-0.96; P = 0.0134). CONCLUSIONS: This retrospective study confirms an association between elevated troponin and outcomes in critically ill patients without ACS and identifies statins, ß-blockers, and aspirin as potential outcome modifiers in a cTn-dependent manner.

Developmental transitions in cardiac conduction.

The proper sequence of electrical activation of the mature four-chambered heart requires specialized conduction pathways including the His-Purkinje system and a nearly complete separation of the atrial and ventricular myocardium. We tracked the emergence of the structure of the mature His-Purkinje system in the developing chicken embryo with anti-polysialylated neural cell adhesion molecule (PSA-NCAM) and the HNK1 antibody against a sulfated carbohydrate epitope. The function of the His-Purkinje system was assayed using extracellular electrodes and high-resolution voltage-sensitive two-dimensional optical mapping. The appearance of the mature form of the His-Purkinje system delineated by the markers coincided with the onset of the mature electrophysiological pattern of ventricular activation. These data suggest that, at the completion of ventricular septation, the His-Purkinje system undergoes critical structural and functional transitions that impact on the global pattern of conduction and contraction of the developing four-chambered heart.

Functional imaging of the embryonic pacemaking and cardiac conduction system over the past 150 years: technologies to overcome the challenges.

Early analyses of cardiac pacemaking and conduction system (CPCS) development relied on classic histology and visual inspection of the beating heart. Current techniques that facilitate delineation of the CPCS include the use of specific antibody markers and transgenic mouse lines specifically expressing reporter genes. Assaying the function of tiny embryonic hearts required an increase in the level of spatial and temporal resolution. Current methods for such analyses include the use of intracellular and extracellular microelectrodes, echocardiography, rapid optical imaging using fluorescent dyes, and most recently optical coherence tomography. This review will focus on methods developed to investigate the functional emergence of the embryonic cardiac conduction system. Where appropriate, the methods used to delineate the anatomic pathways will also be discussed. The combination of techniques to capture both morphological and functional data from the CPCS will further improve with continued interdisciplinary collaboration. The Supplementary Material referred to in this article can be found at the Anatomical Record website (http://www.interscience.wiley.com/jpages/0003-276X/suppmat).

Structure-function relationship in the AV junction.

In the normal heart, the atrioventricular node (AVN) is part of the sole pathway between the atria and ventricles. Under normal physiological conditions, the AVN controls appropriate frequency-dependent delay of contractions. The AVN also plays an important role in pathology: it protects ventricles during atrial tachyarrhythmia, and during sinoatrial node failure an AV junctional pacemaker can drive the heart. Finally, the AV junction provides an anatomical substrate for reentry. Using fluorescent imaging with voltage-sensitive dyes and immunohistochemistry, we have investigated the structure-function relationship of the AV junction during normal conduction, reentry, and junctional rhythm. We identified molecular and structural heterogeneity that provides a substrate for the dual-pathway AVN conduction. We observed heterogeneity of expression of three isoforms of connexins: Cx43, Cx45, and Cx40. We identified the site of origin of junctional rhythm at the posterior extension of the AV node in 79% (n = 14) of the studied hearts. This structure was similar to the compact AV node as determined by morphologic and molecular investigations. In particular, both the posterior extension and the compact node express the pacemaking channel HCN4 (responsible for the I(F) current) and neurofilament 160. In the rabbit heart, AV junction conduction, reentrant arrhythmia, and spontaneous rhythm are governed by heterogeneity of expression of several isoforms of gap junctions and ion channels. Uniform neurofilament expression suggests that AV nodal posterior extensions are an integral part of the cardiac pacemaking and conduction system. On the other hand, differential expression of Cx isoforms in this region provides an explanation of longitudinal dissociation, dual-pathway electrophysiology, and AV nodal reentrant arrhythmogenesis.

Quantitative measurement of blood flow dynamics in embryonic vasculature using spectral Doppler velocimetry.

The biophysical effects of blood flow are known to influence the structure and function of adult cardiovascular systems. Similar effects on the maturation of the cardiovascular system have been difficult to directly and non-invasively measure due to the small size of the embryo. Optical coherence tomography (OCT) has been shown to provide high spatial and temporal structural imaging of the early embryonic chicken heart. We have developed an extension of Doppler OCT, called spectral Doppler velocimetry (SDV), that will enable direct, non-invasive quantification of blood flow and shear rate from the early embryonic cardiovascular system. Using this technique, we calculated volumetric flow rate and shear rate from chicken embryo vitelline vessels. We present blood flow dynamics and spatial velocity profiles from three different vessels in the embryo as well as measurements from the outflow tract of the embryonic heart tube. This technology can potentially provide spatial mapping of blood flow and shear rate in embryonic cardiovascular structures, producing quantitative measurements that can be correlated with gene expression and normal and abnormal morphology.

Emerging patterns of cardiac conduction in the chick embryo: waveform analysis with photodiode array-based optical imaging.

Major difficulties investigating the developing cardiac conduction system stem from that the embryonic heart is extremely small (< 2 mm) and cardiac activation is relatively rapid (< 8 msec). The objective of this study was to investigate the electrophysiology of the embryonic chick cardiac conduction system at periseptation stages with a photodiode array-based detection method of optical mapping capable of high spatial and temporal resolution. Previous work indicated that, in chicken embryos, a switch occurs in ventricular activation pattern from immature base-to-apex to mature apex-to-base pattern at the time of ventricular septation. It was our aim to map activation in more detail to identify the active pathway or pathways of atrioventricular conduction at these particular stages. Analysis of preseptated hearts (n = 10) showed that the latest atrial activation took place just above the site of the earliest ventricular activation at the ventral left ventricular base. Analysis of postseptated hearts (n = 11) showed apex-to-base conduction consistent with activation through the maturing His-Purkinje system. Evaluation of hearts during septation revealed a gradual transition of ventricular activation patterns rather than an abrupt "switch." External pacing of preseptated hearts revealed significant slowing of interventricular conduction compared with spontaneous beats (spontaneous, 61.7 cm/sec +/- 9 cm/sec vs. paced, 36.5 cm/sec +/- 10 cm/sec). The more detailed mapping revealed that, before septation, the pattern of activation of the ventricular myocardium is consistent with direct atrial-ventricular myocardial connections at the left lateral atrioventricular junction; however, functional evidence for a preferential conduction pathway within the ventricles was present before septation.

Sculpting the cardiac outflow tract.

The cardiac outflow tract is the site of anomalies that affect a substantial proportion of individuals with congenital heart defects. The morphogenesis of this site is complex, and requires coordinated development of many cell types and tissues. It is therefore not surprising that developmental mistakes arise here, and that the steps and mechanisms of morphogenesis are still controversial and poorly understood, despite advances in molecular techniques. Recent findings have provided new insight into mechanisms of outflow tract morphogenesis, including clarification of its origins and the fate of cardiomyocytes, as well as invading cell populations. Application of new and old techniques and a wide range of approaches to tackle the unanswered questions about the outflow tract calls for collaboration among investigators from different disciplines including anatomists, physiologists, and molecular biologists.

Initiation of apoptosis in the developing avian outflow tract myocardium.

Apoptosis occurs within the cardiac outflow tract (OFT) myocardium during normal development of chick hearts. This peak of apoptosis occurs at stage 30-31 and coincides with dramatic remodeling of the OFT, suggesting that apoptosis occurs to allow proper alignment of the great vessels over their respective ventricles. The signals that initiate apoptosis in this setting are unknown. The aim of this study was to characterize the cells undergoing apoptosis in the cardiac OFT myocardium and the cells that may influence this process. Two cell populations that may initiate apoptosis of the cardiomyocytes are the cardiac neural crest (CNC) cells and epicardial cells. We examined stage 30-31 chick embryos that had undergone removal of the CNC cells or had delayed epicardial growth for alterations of apoptosis. Removal of the CNC cells did not reduce the levels or pattern of apoptosis in the OFT myocardium. In contrast, impeding the growth of the epicardium over the OFT resulted in a 57% reduction in apoptotic cells in the OFT myocardium. Analysis of the apoptotic cells within the OFT myocardium showed that as many as 92% of them expressed cardiomyocyte markers. In the quail, the endothelial marker QH1 identified a component from the epicardium, endothelial cells, in regions where apoptosis is elevated in the OFT myocardium. These results suggest that a component from the epicardium, possibly endothelial cells, is required for the initiation of apoptosis in OFT cardiomyocytes.

The pros and cons of apoptosis assays for use in the study of cells, tissues, and organs.

Programmed cell death or apoptosis occurs in many tissues during normal development and in the normal homeostasis of adult tissues. Apoptosis also plays a significant role in abnormal development and disease. Increased interest in apoptosis and cell death in general has resulted in the development of new techniques and the revival of old ones. Each assay has its advantages and disadvantages that can render it appropriate and useful for one application, but inappropriate or difficult to use in another. Understanding the strengths and limitations of the assays would allow investigators to select the best methods for their needs.