Endoplasmic Reticulum Stress, NRF2 Signalling and Cardiovascular Diseases in a Nutshell.

PURPOSE OF REVIEW: This short review is intended primarily to summarize the understanding of the interrelated roles of endoplasmic reticulum (ER) stress, oxidative stress and inflammation in cardiovascular diseases. RECENT FINDINGS: Insults interfering with ER function lead to the accumulation of unfolded and misfolded proteins in the ER. An excess of proteins folding in the ER is known as ER stress. This condition initiates the unfolded protein response (UPR). When the UPR fails to control the level of unfolded and misfolded proteins, ER-initiated apoptotic signalling is induced. Moreover, the role of the protective nuclear erythroid-related factor 2 (Nrf2)/antioxidant-related element (ARE) and the activation of the pro-inflammatory nuclear factor-kappa B (NF-kB) are analysed. Authors summarize evidence that oxidative stress, inflammation and ER stress are closely entwined phenomena. They are involved in the pathogenesis of different cardiovascular diseases. Current literature data are presented, focusing on three topics of related pathologies: atherosclerotic plaque, coronary artery disease and diabetes. This review will provide a basic platform for study and application to several other conditions in which oxidative stress, ER stress and inflammation are key features. Future studies in this area may identify the most promising molecules to be investigated as common targets for cardiovascular diseases.

Young smoker "ABCD" vascular assessment: a four-step ultrasound examination for detecting peripheral, extra and intra-cranial early arterial damage.

BACKGROUND: Cigarette smoking is known as a major risk factor in the pathogenic mechanisms of stroke, coronary and peripheral artery disease (CAD and PAD), even in young subjects. The aim of this study is the creation of a four-step ultrasound examination to evaluate and monitor the peripheral, the extra and the intra-cranial assessment of the arterial early damage in smokers. The evaluations of A, the Ankle-brachial index, ABI, B, the Breath holding index, BHI, C, the Carotid intima media thickness, CIMT, and D, the Diameter of the abdominal aorta represent the "ABCD" assessment. METHODS: Thirty-eight healthy smokers and 43 controls underwent A, calculated for each leg. B was calculated after determination of subjects' flow velocity of middle cerebral artery (MCA) by trans-cranial colour Doppler (TCCD) before and after 30 s of apnoea at baseline and just after smoking a cigarette, to simulate the chronic and acute effects of smoking. Finally, C and D evaluation were assessed using a high-resolution B-mode ultrasound. RESULTS: Smokers presented higher values of CIMT (mean and maximal), and lower BHI both at baseline and just after smoking (p < 0.01), though in the normal range. No significant differences were found for A and D between smokers and non- smokers. CONCLUSIONS: Our results underline the importance of the assessment of B and C, that, though in the normal range, present significant differences between smokers and non-smokers. These data could drive the screening between smokers in age-related manner. Moreover, the "ABCD" examination could represent a valid method to detect and then monitor smokers' vascular damage. Although it is far to be considered a screening and routine tool, it should be contemplated in a wider context of possible not-invasive practical screening and follow-up modalities. This would be designed to implement preventive strategies and tools aimed at discouraging tobacco addiction and monitoring cardiovascular risk patients.

Changes in the ultrasound presentation of hepatocellular carcinoma: a center's three decades of experience.

PURPOSE: Ultrasound (US) surveillance is a cornerstone for early diagnosis of HCC, anyway US presentation has undergone significant changes. With the aim of evaluating the effects of US surveillance program in the real-world clinical practice, we wanted to evaluate US presentation of HCCs over the last 30 years and the differences of HCCs presentation according to etiology. METHODS: 174 patients diagnosed between 1993 and 98 (G1), 96 between 2003 and 08 (G2), 102 between 2013 and 18 (G3), were compared. US patterns were: single, multiple or diffuse nodules. The echo-patterns: iso-, hypo-, hyper-echoic, or mixed. In G1, the HCC diagnosis was mainly histologic; in G2 by EASL 2001 and AASLD 2005, in G3 AASLD 2011, EASL 2012, and AISF 2013 guidelines. RESULTS: HCV was the most frequent etiology, dropping between G1 (81%) and G3 (66%) (P < 0.01), metabolic increased between G1 (5%) and G3 (14%) (P < 0.01). Single HCC was more prevalent in G3 vs G1 (65.6% vs 40%) (P < 0.0001), multiple nodules in G1 (50%) vs G3 (33.3%) (P < 0.02) and diffuse in G1 (16%) vs G2 (2%) and vs G3 (1%) (P < 0.001). The most frequent echo-pattern was hypo-echoic G1 (50%) vs G2 (79%) and G1 vs G3 (65%) (P < 0.01). Iso-echoic pattern was the least frequent (7-12%). Mixed pattern decreased from G1 (28%) to G3 (12%) (P < 0.002). In G3 there were more multiple or diffuse HCCs in metabolic (P < 0.03). CONCLUSION: US presentation became less severe due to surveillance programs. HCV remains the most frequent cause, an increase in metabolic etiology has been shown throughout the decades.

The Heart Failure Knights.

The 2021 European Society of Cardiology guidelines for the diagnosis and treatment of acute and chronic heart failure (HF) have abandoned the sequential approach for optimal drug therapy and proposed four drug classes, the so-called 4 "pillars" (angiotensin-converting enzyme inhibitors; angiotensin receptor-neprilysin inhibitors; beta-blockers; mineralocorticoid receptor antagonists and sodium-glucose co-transporter 2 inhibitors) to be initiated and titrated in all patients with reduced ejection fraction HF (HFrEF). In addition, new molecules have been considered, derived from recently reported advances from trials in HFrEF. In this review, Authors examine in particular these new molecules, as further "knights" for HF. In particular, vericiguat, a novel oral soluble guanylate cyclase stimulator, has proved effective in patients with HFrEF who had recently been hospitalized or had received intravenous diuretic therapy. The selective cardiac myosin activator omecamtiv mecarbil and the cardiac myosin inhibitors aficamten and mavacamten are under investigation. Cardiac myosin stimulator, omecamtiv mecarbil, has shown efficacy in HFrEF, lowering HF related events or cardiovascular death, while the 2 inhibitors, mavacamten and aficamten have been shown to reduce hypercontractility and left ventricular outflow obstruction improving functional capacity in randomized trials targeting hypertrophic cardiomyopathy. These agents are the prototypes of active pipelines promising to deliver an array of molecules against HF in the near future.

Oxidative Stress in Chronic and Age-Related Diseases.

The connection between oxidative stress and common age-related diseases presents an exciting field of research [...].

Cardiovascular Diseases: Consider Netosis.

Neutrophil extracellular traps (NETs) are net-like chromatin fibers that are released from dying neutrophils during infections. NETs are a sort of scaffold, ideal to retain microbes. The main function of NETs is the trapping and killing pathogens, as such as bacteria, fungi, viruses (including SARS-CoV-2) and protozoa. The death of neutrophils via NETs formation is called "NETosis." Nevertheless, recent studies suggest that NETosis is involved in several diseases, other than infections. Very recently, it has been shown that NETs formation contributes to venous thromboembolism but also to atherosclerosis progression, creating a link between venous and arterial thrombosis. The presence of NETs in the luminal portion of human atherosclerotic vessels and coronary specimens obtained from patients after acute myocardial infarction has been detected. This review provides evidence of the most important updates about the role of NETs in myocardial infarction, in heart failure and in the process of atherosclerosis itself. The prognostic significance of NETs-related markers in cardiovascular diseases will be discussed, in order to assess targeted therapeutic strategies.

Clonal Hematopoiesis and Cardiovascular Diseases: The Connection.

Atherothrombosis is the leading cause of death worldwide, but the precise mechanisms are not yet fully understood. Traditional cardiovascular risk factors have been known for many years, but are not enough to predict individual risk despite consolidated and emerging risk scoring systems. Clonal Haematopoiesis of Indeterminate Potential (CHIP) refers to the clonal expansion of a population of haematopoietic cells in response to the acquisition of a somatic mutation, without any clinical or biological sign of haematological malignancy. The prevalence of this condition increases with age, reaching 10 to20% of the general population aged >70 years. Recent studies have shown a link between CHIP and cardiovascular diseases. CHIP carriers have higher risk of cardiovascular diseases with also a more severe prognosis. Inflammation and immunity play a critical role in enhancing the cardiovascular consequences of CHIP. In this review we discuss the association between CHIP and cardiovascular diseases focusing on inflammation and other pathways shared with atherosclerosis progression. It is hopeful that in the future patients recognized as CHIP carriers may be classified as high-risk cardiovascular patients and new treatment targets will be required for them.

Diabetic Striatopathy: Case Report and Possible New Actors.

Diabetic striatopathy is a very rare neurological complication of diabetes. We report the case of an 86-year-old woman with poorly controlled type 2 diabetes admitted to the internal medicine ward for sudden onset of altered sensorium and severe bilateral choreiform and ballistic movements. The precise pathophysiology of this condition is not well understood. Our communication aims to remind clinicians to consider the possibility of diabetic striatopathy when poor-controlled diabetic patients have sudden-onset choreiform and ballistic movements. Moreover, this case suggests the possibility that oxidative and endoplasmic reticulum stress may be involved in this process.

The Most Severe Paradigm of Early Cardiovascular Disease: Hutchinson-Gilford Progeria. Focus on the Role of Oxidative Stress.

Oxidative stress (OS) is one of the most frequently recognized causes of ageing. Telomere erosion, defects in the DNA damage response and alterations in the nuclear architecture are also associated with premature ageing. The most severe premature ageing syndrome, Hutchinson-Gilford progeria syndrome (HGPS) is associated with alterations in nuclear shape resulting in the deregulation of lamin A/C. In this review we describe emerging data reporting the role of OS and antioxidant defence in progeroid syndromes focusing on HGPS. We explore precise antioxidant defence mechanisms and related drugs that may create a potential path out of the woods in this disease. Pathways regulated by Nuclear factor E2 related factor (Nrf2), by Nuclear Factor kappa B (NF-kB), and related to the Unfolded Protein Response (UPR) and Endoplasmic Reticulum (ER) stress are under investigation in HGPS patients for which the goal is a significant lifespan extension in particular by postponing atherosclerosis-related complications.

A Five-Step Vascular Ultrasound Examination in Heart Failure: The First Two Years of the "ABCDE" G-SIUMB Multicenter Study 2018-2022.

The aim of this study is the creation of a 5-step ultrasound examination to evaluate and monitor Heart Failure (HF) patients during hospitalization and follow-up. "ABCDE" is the acronym of an Italian multicentre study composed of a consecutive sample of HF patients admitted from the Emergency to the Internal Medicine/Geriatric Departments of several Italian hospitals. The "ABCDE" score includes the evaluations of A, the Ankle-brachial index (ABI), B, the B-lines, C, the Carotid intima media thickness (CIMT), D, the Diameter of the abdominal aorta and of the inferior cave vein and E, the echocardiographic assessment of the ejection fraction. This paper reports the preliminary results. Up to now, the "ABCDE" multicenter study seems an exciting opportunity to create an integrative ultrasound approach in HF. The definitive confirmation of these preliminary results and the effective usefulness of the "ABCDE" will be available in 2022, at the end of the study.

An Exploratory Look at Bicuspid Aortic Valve (Bav) Aortopathy: Focus on Molecular and Cellular Mechanisms.

Bicuspid aortic valve (BAV) is the most common congenital heart malformation. BAV patients are at increased risk for aortic valve disease (stenosis/regurgitation), infective endocarditis, thrombi formation and, in particular, aortic dilatation, aneurysm and dissection. This review aims at exploring the possible interplay among genetics, extracellular matrix remodeling, abnormal signaling pathways, oxidative stress and inflammation in contributing to BAV-associated aortopathy (BAV-A-A). Novel circulating biomarkers have been proposed as diagnostic tools able to improve risk stratification in BAV-A-A. However, to date, the precise molecular and cellular mechanisms that lead to BAV-A-A remain unknown. Genetic, hemodynamic and cardiovascular risk factors have been implicated in the development and progression of BAV-A-A. Oxidative stress may also play a role, similarly to what observed in atherosclerosis and vulnerable plaque formation. The identification of common pathways between these 2 conditions may provide a platform for future therapeutic solutions.

Potential Role of Antioxidant and Anti-Inflammatory Therapies to Prevent Severe SARS-Cov-2 Complications.

The coronavirus disease 2019 (COVID-19) pandemic is caused by a novel severe acute respiratory syndrome (SARS)-like coronavirus (SARS-CoV-2). Here, we review the molecular pathogenesis of SARS-CoV-2 and its relationship with oxidative stress (OS) and inflammation. Furthermore, we analyze the potential role of antioxidant and anti-inflammatory therapies to prevent severe complications. OS has a potential key role in the COVID-19 pathogenesis by triggering the NOD-like receptor family pyrin domain containing 3 inflammasome and nuclear factor-kB (NF-kB). While exposure to many pro-oxidants usually induces nuclear factor erythroid 2 p45-related factor2 (NRF2) activation and upregulation of antioxidant related elements expression, respiratory viral infections often inhibit NRF2 and/or activate NF-kB pathways, resulting in inflammation and oxidative injury. Hence, the use of radical scavengers like N-acetylcysteine and vitamin C, as well as of steroids and inflammasome inhibitors, has been proposed. The NRF2 pathway has been shown to be suppressed in severe SARS-CoV-2 patients. Pharmacological NRF2 inducers have been reported to inhibit SARS-CoV-2 replication, the inflammatory response, and transmembrane protease serine 2 activation, which for the entry of SARS-CoV-2 into the host cells through the angiotensin converting enzyme 2 receptor. Thus, NRF2 activation may represent a potential path out of the woods in COVID-19 pandemic.

Serum Uric Acid Levels, but Not rs7442295 Polymorphism of SCL2A9 Gene, Predict Mortality in Clinically Stable Coronary Artery Disease.

Serum uric acid (SUA) has been associated with cardiovascular disease, but up to now whether SUA is an independent cardiovascular risk factor or merely a disease-related epiphenomenon remains still controversial. within the framework of the Verona Heart Study, we prospectively followed 703 subjects with angiographically demonstrated and clinically stable coronary artery disease between May 1996 and March 2007. At baseline, SUA levels were measured in all the patients. Genotype data of SCL2A9 rs7442295 polymorphism, which has been associated with SUA by genome-wide association studies, were available for 686 subjects (97.6%). After a median follow-up of 57 months, 116 patients (16.5%) had died, 83 (11.8%) because of cardiovascular causes. Patients with hyperuricemia, defined by SUA levels above the 75th percentile (≥0.41 mmol/L), had an increased total and cardiovascular mortality rate than those with SUA below this threshold level (23.3% vs 14.1%, P = 0.048 and 19.4% vs 9.2%, P = 0.001, respectively, by Kaplan-Meier with Log-Rank test). These associations were confirmed by Cox regression after adjustment for sex, age, other predictors of mortality, coronary revascularization, and drug therapies at discharge (hazard ratio for total mortality 1.87 [1.05-3.34], P = 0.033; hazard ratio for cardiovascular mortality 2.09 [1.03-4.25], P = 0.041). Although associated with SUA levels, rs7442295 polymorphism did not predict total or cardiovascular mortality. our data support that SUA may be a prognostic cardiovascular biomarker, predicting total and cardiovascular mortality in the setting of secondary prevention of coronary artery disease. On the other hand, SCL2A9 gene polymorphism, notwithstanding a clear influence on SUA levels, was not associated with mortality.

Spotlight on Cardiovascular Scoring Systems in Covid-19: Severity Correlations in Real-world Setting.

OBJECTIVES AND METHODS: the current understanding of the interplay between cardiovascular (CV) risk and Covid-19 is grossly inadequate. CV risk-prediction models are used to identify and treat high risk populations and to communicate risk effectively. These tools are unexplored in Covid-19. The main objective is to evaluate the association between CV scoring systems and chest X ray (CXR) examination (in terms of severity of lung involvement) in 50 Italian Covid-19 patients. Results only the Framingham Risk Score (FRS) was applicable to all patients. The Atherosclerotic Cardiovascular Disease Score (ASCVD) was applicable to half. 62% of patients were classified as high risk according to FRS and 41% according to ASCVD. Patients who died had all a higher FRS compared to survivors. They were all hypertensive. FRS≥30 patients had a 9.7 higher probability of dying compared to patients with a lower FRS. We found a strong correlation between CXR severity and FRS and ASCVD (P < 0.001). High CV risk patients had consolidations more frequently. CXR severity was significantly associated with hypertension and diabetes. 71% of hypertensive patients' CXR and 88% of diabetic patients' CXR had consolidations. Patients with diabetes or hypertension had 8 times greater risk of having consolidations. CONCLUSIONS: High CV risk correlates with more severe CXR pattern and death. Diabetes and hypertension are associated with more severe CXR. FRS offers more predictive utility and fits best to our cohort. These findings may have implications for clinical practice and for the identification of high-risk groups to be targeted for the vaccine precedence.

Progeria, atherosclerosis and clonal hematopoiesis: links and future perspectives.

The main actors of this review are Hutchinson-Gilford progeria syndrome (HGPS) and atherosclerosis. HGPS is a very rare disease with no definitively approved specific drugs. Atherosclerosis is a very common disease with a more consolidated treatment strategy. Nevertheless, common mechanisms are shared by both these diseases, particularly related to inflammation, oxidative and endoplasmic reticulum (ER) stress. Pathways regulated by Nuclear factor E2 related factor (Nrf2), Nuclear factor kappa B (NF-kB) and related to the Unfolded Protein Response (UPR) and ER stress are receiving increasing attention. In HGPS "not omnia" happen(s) "cum tempore", that means that HGPS patients have atherosclerotic complications before their time. The third actor is clonal hematopoiesis: it constitutes a link between ageing and atherosclerosis. This review aims to analyse the current knowledge of atherosclerosis and clonal hematopoiesis in order to suggest therapeutic strategies to correct the timing of the atherosclerosis progression in HGPS. The goal for HGPS is a shift from "not omnia cum tempore" to "omnia cum tempore" in terms of significant lifespan extension by postponing atherosclerosis-related complications.

Evidence of major genes effects on serum homocysteine and fibrinogen levels, and premature ischemic heart disease in Italian extended families.

OBJECTIVES: The purpose of the present study was to investigate the effect of novel genetic factors on plasma levels of total homocysteine (tHcy) and fibrinogen (FIB). As tHcy and FIB have been consistently associated to increased risk of ischemic heart disease (IHD) and acute myocardial infarction (MI) also genes-trait-MI mediational effects were tested. METHODS: A complex segregation analysis, and a mediation analysis of a highly selected group of 44 extended families (302 subjects), each including at least one member with fatal premature (<50 years) IHD were carried out. RESULTS: tHcy and FIB levels turned out to be influenced by at least two major genes. A significant tHcy latent class-MI association (OR = 3.24; 95% CI, 1.37 to 7.68), and a non-significant tHcy plasma level-MI association (OR = 1.65 per 1 = log 10 mumol/l, 95% CI, 0.56 to 4.81) were estimated, suggesting a direct influence of the homocysteine major gene as suppressor of plasma tHcy levels effect. In contrast, FIB latent class-MI association (OR = 0.97; 95% CI, 0.31 to 3.05) and FIB level-MI association (OR = 1.32 per 1 = 70 g/l; 95% CI, 0.88 to 2.00) were not statistically significant. CONCLUSION: These data provide evidence for a major latent gene effect influencing variation in tHcy plasma levels, which is independent on C677T MTHFR polymorphism, and significantly affecting the risk of MI.

Ultrasound as First Line Step in Anaemia Diagnostics.

This review covers the role of ultrasonography as an essential non-invasive diagnostic approach when facing patients with anaemia, a common clinical problem. Abdomen ultrasound is well recognised as a first-line examination in the setting of blood loss, both acute and chronic. Less is clear about the additional opportunities, given by ultrasound in anaemia, due to the many other possible causes. Here we provide information on the utility of ultrasound in different contexts and a practical guide for clinicians facing anaemic patients.

Ultrasonography in Heart Failure: A Story that Matters.

Heart failure (HF) is a clinical syndrome caused by structural and/or functional cardiac abnormalities, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress. It is the leading cause of hospitalization in Internal Medicine departments. This article aims at reviewing evidence of the importance of ultrasound in HF both for hospitalized patients and in the follow-up. Ultrasound may be used as a recovery monitoring instrument at the bedside and also as a global cardiovascular assessment tool for these patients. HF represents an exciting opportunity to create an integrative ultrasound approach in Internal Medicine and/or Geriatric departments. The authors plan a five-step ultrasound examination to evaluate and monitor HF patients during hospitalization and follow-up. They call this examination: the "ABCDE" score. It includes the evaluations of A, the ankle-brachial index, B, the B-lines, C, the carotid intima media thickness, D, the diameter of the abdominal aorta and of the inferior cava vein and E, the echocardiographic assessment of the ejection fraction. This score may represent an integrative ultrasound approach in Internal Medicine and/or Geriatric departments.

Effects of nebivolol on endothelial gene expression during oxidative stress in human umbilical vein endothelial cells.

The endothelium plays a key role in the development of atherogenesis and its inflammatory and proliferative status influences the progression of atherosclerosis. The aim of this study is to compare the effects of two beta blockers such as nebivolol and atenolol on gene expression in human umbilical vein endothelial cells (HUVECs) following an oxidant stimulus. HUVECs were incubated with nebivolol or atenolol (10 micromol/L) for 24 hours and oxidative stress was induced by the addition of oxidized (ox)-LDL. Ox-LDL upregulated adhesion molecules (ICAM-1, ICAM-2, ICAM-3, E-selectin, and P-selectin); proteins linked to inflammation (IL-6 and TNFalpha), thrombotic state (tissue factor, PAI-1 and uPA), hypertension such as endothelin-1 (ET-1), and vascular remodeling such as metalloproteinases (MMP-2, MMP-9) and protease inhibitor (TIMP-1). The exposure of HUVECs to nebivolol, but not to atenolol, reduced these genes upregulated by oxidative stress both in terms of protein and RNA expression. The known antioxidant properties of the third generation beta blocker nebivolol seem to account to the observed differences seen when compared to atenolol and support the specific potential protective role of this beta blocker on the expression of a number of genes involved in the initiation and progression of atherosclerosis.

Nuclear factor kappa B in patients with a history of unstable angina: case re-opened.

This study aims at assessing NF-kB activity in unstable angina (UA) patients free of symptoms after a 1 year follow-up (1YFU). Plasma oxidized low-density lipoproteins (oxLDL), circulating NF-kB, Interleukin 6 (IL-6) and Interleukin 1ß (IL-1ß), high-sensitivity C-reactive protein (hs-CRP), as markers of oxidative stress and inflammation and plasma double-stranded DNA (ds-DNA), as marker of Neutrophil Extracellular Traps (NETs), were measured in 23 of the previously enrolled 27 UA patients. These measurements were compared to the UA data at baseline, and then compared to the data derived from the stable angina (SA) and controls (C) enrolled in our previous study (we demonstrated that UA had higher levels of NF-kB compared to SA and C). After a 1YFU, UA patients show a significant decrease in NF-kB, IL-6, hs-CRP, oxLDL, and ds-DNA plasma levels (p < 0.001) and in IL-1ß and White Blood Cells (WBC) (p < 0.005), without differences in lipid and glucose assessment. If compared to SA and C, UA after a 1YFU have higher levels of NF-kB, IL-6, ds-DNA, WBC, and oxLDL compared to C (p < 0.001), but only IL-6 is higher than SA (p < 0.001). No differences are found in lipid and glucose assessment. After a 1YFU, patients with a history of UA improve their oxidative and inflammatory status, such as the levels of circulating ds-DNA, without achieving the status of C. They become comparable to SA subjects. This study provides new insight on the multiple and apparently contradictory facets of NF-kB in UA and on its possible role as mediator in NETs' formation.