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Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

Copyright 2007 Saunders, An Imprint of Elsevier

CHAPTER 29 Emerging Therapies and Strategies in the Treatment of


Heart Failure
Stefanie Dimmeler Douglas L. Mann Andreas M. Zeiher
Nonpharmacological Strategies, 697
Myocardial Repair and Regeneration, 697
Stem/Progenitor Cells, 697
Mechanisms of Action of Stem Cells, 699
Tissue Engineering, 700
Clinical Application of Stem Cells, 700
Cell Therapy in Acute Myocardial Infarction, 701
Mobilization Strategies in Acute Myocardial Infarction, 703
Cell Therapy and Cell Mobilization Strategies in Patients with Chronic Heart Failure, 704
Future Perspectives in Myocardial Repair and Regeneration, 705
Gene Therapy, 706
Future Perspectives in Gene Therapy, 707
Pharmacological Strategies, 708
Pharmacogenetics, 708
Future Perspectives in Pharmacogenetics, 710
Metabolic Modulation, 710
Future Perspectives in Metabolic Modulation, 711
Immunomodulation, 712
Future Perspectives in Immunomodulation, 714
References, 714
Our current therapeutic approach to the treatment of heart failure (HF) relies on treating
patient symptoms using digitalis and diuretics, using neurohormonal antagonists such as
angiotensin converting enzyme inhibitors (ACEIs) and/or angiotensin receptor blockers,
beta blockers, and aldosterone antagonists to prevent disease (see Chap. 25) , as well as the
use of biventricular pacemakers and defibrillators in appropriate patient populations (see
Chaps. 25 and 34) . Despite these pharmacological and device interventions, HF remains a
progressive disease with an unacceptably high mortality and morbidity. Thus, there is an
ongoing need for new and improved therapeutic approaches for the treatment of HF. In this
chapter, we will review some of the new therapeutic approaches that are being evaluated in
patients with HF. The organization of this chapter will focus first on new

nonpharmacological strategies in HF, including the exciting concept of myocardial repair


and regeneration; a review of emerging pharmacological strategiessuch as
pharmacogenomics; and a discussion of novel targets in HF. New and emerging surgical
approaches to HF are reviewed in Chap. 27 .

NONPHARMACOLOGICAL STRATEGIES
Myocardial Repair and Regeneration
As noted in Chap. 22 , HF may develop as a consequence of myocyte loss or dysfunction,
eventually leading to left ventricular remodeling and cardiac decompensation. Replacement
of dead or dysfunctional cardiac myocytes through cell-based therapies represents a logical
and novel option for the treatment of HF. As will be discussed subsequently, cell-based
therapies may achieve true cardiac regeneration by renewing the pool of functionally active
cardiac myocytes, or may lead to cardiac repair by supporting neovascularization,
supplementing and/or augmenting the cytoprotective mechanisms that occur naturally, or by
favorably influencing the remodeling processes. The promise of cellular cardiomyogenesis,
neovascularization, and additional cell-mediated beneficial effects, individually or in
combination, offers altogether novel opportunities for tailored treatment of the underlying
pathobiology.

Stem/Progenitor Cells
In general, two types of stem cells should be discussed separately: embryonic stem cells and
adult stem cells ( Fig. 29-1 ). Whereas embryonic stem (ES) cells clearly have the capacity
to give rise to all cell types of the body and are able to form tissues and organs, most adult
stem cells are more specific (more lineage committed) and the use of adult stem cells for
organogenesis has not yet been explored. Embryonic stem cells are derived from the inner
cell layer of the early embryonic trophoblast and can be propagated in cell culture in an
undifferentiated state infinitely. By changing the cultivation conditions (the so-called
hanging drop technique), embryonic stem cells aggregate and form embryoid bodies, an
early embryonic tissue consisting of all three germ layers. Within an embryoid body,
approximately 5 to 10 percent of embryonic stem cells spontaneously differentiate into
cardiomyocytes. Functionally active cardiomyocytes (ESC-CM) have been generated from
mouse as well as from human ES cells (hESC-CM), although the E-C coupling properties of
hESC-CM differ from the adult myocardium.[1] ES cell-derived cardiomyocytes show
macromolecular sarcomeric organization, calcium sparks, ionic currents, functional and
anatomical integration with surrounding cardiomyocytes, and propagation of electrical
activity as well as pacemaker activity.[1] Collectively, these data demonstrate that ES cells
spontaneously differentiate into fully functionally active, fetal-like cardiomyocytes in vitro.
Although these in vitro data would suggest that ES cells are ideal candidates for in vivo
cardiac repair, animal studies have shown a dose-dependent incidence of tumor formation,
in particular, teratocarcinoma formation, after transplantation of ES cells into mice. Several
strategies aiming to specifically select differentiated cardiomyocytes to exclude highly
proliferating ES cells with a tumor-forming capacity are currently being tested. An
additional question relates to the immunogenic activity of ES cells in an allogenic setting. It
is unclear whether the low immune privilege proposed by experimental studies is
maintained when the ES cells are differentiated and functionally integrated into the human

heart for a long time. Therefore, the safety of ES cell transplantation remains an unsolved
question.[2]

FIGURE 29-1 Cell types and mode of delivery of cells for cardiac repair. A, Cell types used for
cardiovascular repair. B, Delivery strategies used in the clinical setting for cell therapy. MSCs =
mesenchymal stem cells. (From Dimmeler S, Zeiher AM, Schneider MD: Unchain my heart: The
scientific foundations of cardiac repair. J Clin Invest 115:572-583, 2005.)

Adult stem cells comprise at least three different groups: bone marrow-derived stem cells,
the circulating pool of stem or progenitor cells (which at least in part are derived from the
bone marrow), and tissue-resident stem cells (see Fig. 29-1 ). Bone marrow-derived stem
cells are the best studied and were used in most of the clinical trials performed thus far.
Bone marrow contains a complex assortment of progenitor cells, including hematopoietic
stem cells (HSCs), the so-called side population cells (SP cells, defined by the expression
of the Abcg2 transporter allowing export of Hoechst dye),[3] mesenchymal stem cells
(MSCs) or stromal cells,[4] and multipotential adult progenitor cells (MAPCs), a subset of
MSCs.[5]
Circulating blood-derived progenitor cells were initially discovered when searching for proangiogenic cells for therapeutic vasculogenesis. Asahara and Isner isolated endothelial
progenitor cells (EPCs), which were defined by their ability to form new blood vessels and
enhance neovascularization after ischemia (for review see references 6 and 7 [6] [7]). Based
on the assumption that these cells may represent adult hemangioblasts, these cells were
characterized by the expression of hematopoietic markers, such as CD133+ or CD34+, and
endothelial markers for VEGF-receptor 2 (KDR or flk-1). However, it is evident that these
circulating progenitor cells (particularly when cultured in vitro) comprise several different
entities.[6] Individual cells may have clonal potential and stem cell characteristics. Others,
including distinct myeloid subpopulations, may preferentially act as pro-angiogenic cells,[8]
in addition to their capacity to differentiate to endothelial cells. Myeloid cells also have
been shown to contribute to muscle regeneration by fusion, indicating that myeloid
subpopulations may act diversely. An interesting source of endothelial progenitor cells is
placental cord blood, which is enriched in clonally expandable endothelial progenitor cells.
Mesoangioblasts are vessel-associated multipotent progenitors that express the key marker
of angiopoietic progenitors, VEGF-receptor 2, but are distinct from hematopoietic
endothelial progenitor cells. In vitro mesoangioblasts differentiate into many mesoderm cell
types, such as smooth, cardiac and striated muscle, bone and endothelium, and they improve
skeletal muscle dystrophy and heart function. [9] [10] Mesoangioblasts may represent not only
a source of progenitors for therapeutic applications, but also may establish a lineage
relationship between progenitors of vascular and extravascular mesodermal tissues.
The discovery of tissue-resident stem cells in the heart, the cardiac stem cells, offers the
potential to harvest cells, which are primed to acquire a cardiac phenotype and, therefore,
might be optimally suited for cardiac repair. Several different populations have been
identified and characterized: c-Kit+ cells,[11] Sca-1+ cells,[12] SP cells, and cells expressing
the protein Islet-1.[13] Whereas c-Kit+ cells, Sca-1+ cells and cardiac SP cells are isolated
from adult hearts, cells expressing Islet-1 so far have only been detected in the postnatal
stage. Whether c-Kit+, Sca-1+, and cardiac SP cells comprise three different cell
populations is not entirely resolved. At least Sca-1+ cells contain a fraction of SP cells and,
among cardiac SP cells, the greatest potential for cardiomyogenic differentiation is
restricted to cells positive for Sca-1 expression (but negative for CD31)[14]indicating that
the two cell populations may share some common features. Cardiac stem cells also were
obtained by growing self-adherent clusters (termed cardiospheres) from subcultures of
murine or human biopsy specimens. Others have generated cardiac SP cellderived
cardiospheres by adapting a method used for creating a neurosphere and claimed that

cardiac neural crest cells contribute to cardiac SP cells.[15] Cardiosphere-derived cardiac


stem cells as well as c-Kit+ cardiac stem cells are capable of long-term self-renewal and can
differentiate into the major specialized cell types of the heart: myocytes and vascular cells
(i.e., cells with endothelial or smooth muscle markers). So far, the origin and the
mechanisms maintaining the cardiac stem cell pool are unclear. Whereas two recent studies
suggested that c-Kit+ and cardiac SP cells may derive from the bone marrow, [16] [17] these
studies cannot entirely exclude that specific subpopulations of cardiac stem cells originate
from distinct sources and may represent remnants from embryonic development in selected
niches within the heart.
Adipose tissue is a rich source of distinct subsets of stem/progenitor cells potentially useful
for cardiac repair and neovascularization improvement.[18] Both MSCs and endothelial
progenitor cells were isolated after enzymatic digestion of adipose tissue and showed
beneficial effects in experimental studies. Very recently, pluripotent spermatogonial stem
cells from adult mouse testis have been identified, which possess the capacity to
differentiate to fully active cardiac myocytes in vitro.[19]
In summary, the identification and characterization of stem/progenitor cell populations with
potential therapeutic properties for the treatment of heart disease is an emerging field. Since
direct side-by-side comparisons are missing, it is impossible to estimate what might be the
best cell(s) for cardiac repair. Clearly, a ranking will not only be based on the assessment of
the functional capacities of the cells to differentiate into cardiac myocytes, but also will
include other aspects of progenitor cell functions. Particularly, for the clinical application,
the safety of the treatment and the feasibility will be of major importance.

Mechanisms of Action of Stem Cells


In contrast to ES cells, most adult stem or progenitor cells do not spontaneously
differentiate into cardiomyocytes but rather require an adequate stimulus to do so. The local
microenvironment plays an important role to induce cell fate changes by physical cell-tocell interaction and/or by providing paracrine factors ( Fig. 29-2 ). Based on this concept, a
co-culture technique was developed whereby stem or progenitor cells are cultured together
with rat neonatal ventricular cardiomyocytes to simulate a cardiac-like environment in
vitro.[20] Using such a co-culture system to induce differentiation of adult stem or progenitor
cells from various species and organs demonstrated that the physical contact with beating
neighboring cardiomyocytes is indeed required for the differentiation process to occur.
Alternatively, the nonspecific transcriptional activator, the demethylating agent 5azacytidine, induced cardiac differentiation in Sca-1+ cardiac stem cells and MSCs
suggesting a potential role for epigenetic control of changes in cell fate. The neurohormone
oxytocin or cytokines of the Wnt or PDGF family have been employed to induce or enhance
differentiation of adult stem cells ( Table 29-1 ). However, experimental studies addressing
the capacity of bone marrow-derived stem cells to differentiate into the cardiomyogenic
lineage yielded conflicting results, and the extent to which differentiation into cardiac
myocytes occurs in vivo varies dramatically between the different experimental studies. The
identification of subsets of adult stem cells with a higher capacity to differentiate into
cardiac myocytes and the enhancement of cardiac differentiation by interacting with the
pathways controlling differentiation are currently under investigation. Interestingly,

functional improvement of the heart was seen even in experimental studies, where no
formation of new cardiomyocytes was detected. Therefore, additional mechanisms initiated
by cell therapy most likely contribute to functional cardiac repair ( Fig. 29-3 ).

FIGURE 29-2 Homing of bone marrow-derived stem cells to the myocardium. The fate of bone
marrow-derived stem cells is determined by the microenvironment that they enter. (From Anversa P,
Leri A: Myocardial rengeneration. In Zipes DP, Libby P, Bonow RO, Braunwald E [eds]:
Braunwald's Heart Disease, 7th ed. Philadelphia, Elsevier, 2004, p 1917.)

TABLE 29-1 -- Soluble Factors Influencing Cardiac Stem Cell Differentiation


Factor
Cell Type
Citation
PDGF-AB

Murine BMC

Xaymardan, et al., Circ Res 2004

Wnt3a

Murine PC19 cells

Nakamura, et al., PNAS 2003

Wnt11

Human EPC

Koyanagi, et al., JBC 2005

MSC

Bedada, et al., MCB 2005

Murine ES cells

Termai, et al., BBRC 2004

5-azacytidine MSC

Makino, et al., JCI 1999

Factor

Cell Type

Citation

Murine Sca-1+ cardiac stem cells Oh, et al., PNAS 2003


Oxytocine

Murine PC19 cells

Paquin, et al., PNAS 2002

Murine Sca-1+ cardiac stem cells Matuura, et al., JBC 2004


TGF

Murine c-Kit+ BMC

Li, et al., Circulation 2005

BMP

Murine P19CL6 cells

Monzen, et al., MCB 1999

Noggin

Murine ES cells

Yauasa, et al., Nat Biotechnology 2005

Ascorbic acid Murine ES cells

Takahashi, et al., Circulation 2003

BMC = bone marrow mononuclear cells; EPC = endothelial progenitor cells; ES cells =
embryonic stem cells; MSC = mesenchymal stem cells.

FIGURE 29-3 Proposed mechanisms of action of stem/progenitor cells in cardiovascular repair.

In addition to transdifferentiation of stem cells, several other mechanisms should be


considered, including enhanced neovascularization, alterations in scar formation, and
cytoprotection (see Fig. 29-3 ). Of these, most obviously, progenitor cells may improve
neovascularization and thereby augment nutrients and oxygen supply. This mode of action
is expected to contribute to cardiac regeneration, particularly in situations in which blood
supply is limited (e.g., as in chronic ischemic HF with angina pectoris), or alternatively in
the presence of hibernating myocardium. Neovascularization can be mediated by the
physical incorporation of progenitor cells into new capillaries[21] or by perivascular
accumulation of cells. Incorporated progenitor cells of most, if not all, types may release
growth factors that promote angiogenesis by acting on mature endothelial cells.[22] Paracrine
factors may also beneficially influence cardiac repair by protecting cardiac myocytes from
apoptotic stimuli or activate cardiac-resident stem cells to enhance the endogenous repair
capacity. [22] [23] Finally, the release of various cytokines will affect cardiac remodeling
processes by altering the development of fibrosis development during scar formation and/or
by modulating inflammatory processes. The extent to which progenitor cells contribute to
vasculogenesis by becoming physical elements of newly formed vessels versus acting
through secreted factors may depend on the environment to which the cells are exposed.
Importantly, human bone marrow-derived angioblasts were shown to exert angiogenic as
well as paracrine effects.

Tissue Engineering
In contrast to cell therapy, where individual cells are supposed to integrate in the scar tissue,
tissue engineering in its pure sense aims at providing tissue grafts. Larger constructs of
heart muscle can be generated by using heart cell populations to form engineered heart
tissue. So far, it has been challenging to generate tissue in vitro with contractile force and at
a size sufficient to support the failing heart. Several culture conditions have been used in
combination with cell mixtures (e.g., neonatal cardiomyocytes, fibroblasts, skeletal
myoblasts, adult and embryonic stem cells) for creating myocardial tissue in vitro.
Implantation of engineered rat heart tissue from neonatal rat cardiomyocyte in rats after
myocardial infarction improved the contractile function and was shown to be electrically
coupled to the native myocardium.[24] Others have used engineered tissue constructs
containing skeletal muscle derived cells, and the authors claimed that skeletal muscle
cellsin contrast to the results achieved with skeletal muscle cell therapyare electrically
coupled by Gap junctional proteins.[25] Embryonic stem cells are alternative sources for the
generation of heart tissue in vitro.[26] The size of the engineered heart tissue constructs
(unless vascularized and perfused) is limited by oxygen diffusion. Therefore, researchers
have fused several individually cultured single engineered tissue rings.
At the interface between tissue engineering and cell therapy, the development of novel
biomaterials has gained increasing interest. Novel biomaterials have been developed to be
used as ventricular restraints and to provide scaffolds for in vitro tissue engineering. [27] [28] In
addition, the injection of new biomaterial such as self-assembling nanofibers can adapt the
intramyocardial cellular microenvironments to augment homing and functional integration
of cells for in situ tissue engineering and subsequent cardiac regeneration and repair.

Clinical Application of Stem Cells

Clinically Used Cell Types


Currently, a variety of autologous adult progenitor cells are undergoing clinical evaluation.
The first clinically relevant cells proposed for cardiac myocytes were skeletal muscle
myoblastsundifferentiated proliferation-competent cells that serve as precursors to
skeletal muscle.[29] For clinical use, autologous human myoblasts are isolated from skeletal
mus-cle biopsies, propagated and expanded ex vivo for a few days or weeks, then injected
directly into the ventricular wall. Bone marrow is, at present, the most frequent source of
stem cells used clinically for cardiac repair. The rapid transition from the bench to the clinic
was facilitated by the more than 30 years of clinical experience and the excellent safety
profile of infused bone marrow-derived mononuclear cells for bone marrow transplantation.
Bone marrow is aspirated under local anesthesia in most of the studies, the entire
mononuclear cell fraction is obtained (a heterogeneous mixture of cells with varying
percentage of hematopoietic stems cells [HSC], EPC, MSC, and SP cells). So far, isolated
bone marrow-derived cells have been injected into the heart without further ex vivo
expansion. In a few studies, specific subpopulations such as a fraction of hematopoietic and
endothelial progenitor cells expressing the marker protein CD133+ were purified and used.
Peripheral blood-derived progenitor cells are used both for clinical cardiac repair and
peripheral ischemia. Historically, these circulating EPCs are the basis for virtually all
clinical studies that have used bone marrow or its circulating derivatives for the treatment of
ischemic myocardium. The circulating blood-derived cells that have been used so far are
isolated from mononuclear blood cells and selected by culturing the cells in endotheliumspecific medium for 3 days. [30] [31] Alternatively, a specific subfraction, the hematopoietic
CD34+ progenitor cell, is enriched from whole blood following G-CSFmediated
mobilization from the bone marrow into the blood (Losordo and colleagues, personal
communication).

ROUTES OF APPLICATION.
Progenitor cells for cardiac repair can be delivered in different ways (see Fig. 29-1 ):
Intracoronary infusion using standard balloon catheters has been used in all clinical trials
treating patients with acute myocardial infarction. This technique offers the advantage
that cells can travel directly only into myocardial regions in which nutrient blood flow
and oxygen supply are preserved, thereby ensuring a favorable environment for cell
survival, a prerequisite for stable engraftment. Conversely, homing of intraarterially
applied progenitor cells requires migration out of the vasculature into the surrounding
tissue, which may mean that unperfused regions of myocardium will be targeted far less
efficiently, if at all. Whereas bone marrow-derived and blood-derived progenitor cells are
known to extravasate and migrate to ischemic areas, other cell types may not, and they
may even obstruct the microcirculation after intraarterial administration, leading to
embolic myocardial damagethus limiting the use of intracoronary delivery.
Injection of cells into the ventricular wall via a percutaneous endocardial or surgical
epicardial approach is an alternative delivery strategy circumventing some of these
limitations: Direct delivery of progenitor cells into scar tissue or areas of hibernating
myocardium by catheter-based needle injection, direct injection during open-heart

surgery, and minimally invasive thoracoscopic procedures are not limited by cell uptake
from the circulation or by embolic risk. An offsetting consideration is the risk for
ventricular perforation, which may limit direct needle injection into freshly infarcted
hearts. In addition, it is hard to envisage that progenitor cells injected into uniformly
necrotic tissuelacking the syncytium of live muscle cells that may furnish instructive
signals, and lacking blood flow for the delivery of oxygen and nutrientswould receive
the necessary cues and environment to engraft and differentiate. Most cells, if injected
directly, simply die. For this reason, electromechanical mapping of viable but
hibernating myocardium may be useful to pinpoint the preferred regions for injection.
Finally, in diffuse disease-like dilated nonischemic cardiomyopathy, focal deposits of
directly injected cells might be poorly matched to the underlying anatomy and
physiology. Thus, it is likely that nature of the patients' cardiomyopathy will ultimately
influence, if not dictate, the source and route chosen among potential progenitor cell
therapies. Additional strategies to augment cell homing and promoting homogeneous
integration of cells may be required, particularly in patients with chronic healed infarcts
or diffuse nonischemic cardiomyopathy lacking active recruitment signals.

Results of Clinical Trials


The results of clinical trials published to date, aiming at progenitor cell-based myocardial
repair, are summarized in Tables 29-2 and 29-3 [2] [3]. It is essential to distinguish between
studies performed in patients with acute myocardial infarction (see Table 29-2 ) and in
patients with chronic HF (see Table 29-3 ), because fundamentally different
pathophysiological processes are targeted. In patients with acute myocardial infarction,
progenitor cell transplantation aims to prevent or ameliorate postinfarction left ventricular
remodeling, thereby reducing post-infarction HF. Such an effect might be achieved by
enhanced neovascularization and reduced cardiomyocyte apoptosis, irrespective of longterm engraftment and transdifferentiation. Conversely, the former two mechanisms acting
alone may have limited benefit in patients with long-established scars, absent hibernating
myocytes and end-stage HF, where cardiomyogenesis in its pure sense would be desirable.
TABLE 29-2 -- Studies with Infusion/Injection of Progenitor Cells in Patients with Acute
Myocardial Infarction
Days
Patient after Cell
Cell Number
Myocardial
Study
No.
AMI Type
Cell Preparation (106)
Safety
Function
Pilot Trials (Phase I/II)
Strauer, et
al.[32]

N = 10 8
(Nov
03: N =
40)
versus
ctrl.

BMC

40 ml

28

Regional
contractility

(LVA)

Study

Days
Patient after Cell
No.
AMI Type

Cell Number
Cell Preparation (106)
Safety

Myocardial
Function

Ficoll
overnight Teflon

End systolic
volume

(LVA)
Perfusion

(Szinti)
TOPCARE 59
= AMI[30]

4.9

CPC

250 ml/3 day


culture

16

Global
contractility

(LVA/MRI)
BMC

50 ml/Ficoll
same day

213

End systolic
volume

(LVA/MRI)
Viability

(MRI)
Flow reserve

(Doppler)
Fernandez- 20
Aviles[34]

13.5 BMC

50 ml

78

Global
contractility

(MRI)
Ficoll
overnight Teflon

End systolic
volume

Study

Days
Patient after Cell
No.
AMI Type

Cell Number
Cell Preparation (106)
Safety

Myocardial
Function

(MRI)
Ruan, et
al.[56]

10
versus
(rand.)

100

BMC
versus
saline

Global
contractility

(LVA)
Bartunek, et 12
al.[57]

14

CD133 Mouse antibody


+ BMC

Stenosis? Global
contractility

(LVA)
Chen, et
al.[58]

34
versus
35

18

B-MSC 10 day culture


versus
control

Global
contractility

(LVA)
Randomized Trials
Single/Two Center(s)
BOOST[33]

60

1:1
rand.

4.8

BMC
versus
rand.

Gelatin control polysuccinate +


same day
2460
infusion

6 Months:

Global
contractility

(MRI)
18 Months:
No
significant
difference
(MRI)
18 Months:
Diastolic

Study

Days
Patient after Cell
No.
AMI Type

Cell Number
Cell Preparation (106)
Safety

Myocardial
Function
dysfunction

(Echo)
Janssens, et 67
al.[35]

<24
h

BMC
versus
i.c.
placebo

Ficoll density
gradient
centrifugation
few hours after
acute PCI

304

1:1
rand.

Global
contractility
no change

Infarct size

(MRI)
ASTAMI[36] 100

BMC
versus
rand.

Lymphoprep
controlnext
day infusion

87

Global
contractility
no change

Global
contractility

1:1
rand.
MulticenterPlacebo-Controlled, Double-Blind
REPAIR 1 : 1
204 AMI[37] rand.

BMC
versus
i.c.
placebo

Ficoll density
234
gradient
centrifugation
same or next day
infusion

(QLVA)
AMI = acute myocardial infarction; BMC = bone marrow-derived progenitor cells; CPC =
circulating progenitor cells; i.c. = intracoronary; LVA = left ventricular angiography; MRI
= magnetic resonance imaging; QLVA = quantitative LVA; rand. = randomized trial.

TABLE 29-3 -- Studies with Infusion/Injection of Progenitor Cells in Patients with Old
Myocardial Infarction or Chronic Heart Failure
Status Post
Safety and Functional
Study
N
MI
Cells
Application Assessment
Application with NOGA

Study

Status Post
MI
Cells

Tse, et al.[59]

N=8

Old MI

BMC

Application
IM with
NOGA

Safety and Functional


Assessment
Safe
Wall motion and

thickening
Fuchs, et al.

[50]

N = 10

Old MI

BMC

N = 21
Perin, et al.[49]

Control N = Old MI
7

BMC

IM with
NOGA

Safe

IM with
NOGA

Global contractility

BMC N =
14

Safe

End systolic volume

Application During Surgery


Stamm, et al.[60] N = 12

>10 days
after AMI

CD
133+
BMC

IM during
CABG

Safe
Global contractility

Perfusion
Hamano, et
al.[61]

N=5

Galinanes, et
al.[51]

BMC N =
11

Old MI

BMC

IM during
CABG

Safe

Old MI

BMC

IM during
CABG

Safe

N = 34

CABG N =
11

Global contractility

CABG +
BMC: N =
10
Intracoronary Administration
IACT[52]

N = 18

Old MI

BMC

Intracoronary

Safe

Study

Status Post
MI
Cells

Application

5 months to
8.5 years

Safety and Functional


Assessment
Global contractility

(LVA/MRI)

Viability
TOPCARE
CHF[53]

N = 92

Old MI

Control N = 3 months23
12 years

BMC
CPC

Intracoronary

(pet)

Safe
Global contractility

(BMC better than


CPC) (lva)
BMC N =
35
CPC N = 34
BMC = bone marrow-derived progenitor cells; CABG = coronary artery bypass graft; CHF
= congestive heart failure; CPC = circulating progenitor cells; IM = intramuscularly; MI =
myocardial infarction.

Cell Therapy in Acute Myocardial Infarction


As summarized in Table 29-2 , the published studies overall demonstrate that the infusion
of autologous bone marrow mononuclear cells (BMCs) is safe and feasible in patients with
acute myocardial infarction. The study by Strauer,[32] the TOPCARE-AMI,[30] the BOOSTtrial[33] and the study performed by Fernandez-Aviles[34] reported nearly identical results;
that is, an improvement in global LV ejection fraction by 7 to 9 percent, a significant
reduction in LV end-systolic volume, and improved perfusion in the infarcted area 4 to 6
months after cell transplantation. Whereas the randomized, controlled trial by Janssens[35]
did not reveal a significant effect on global ejection fraction, it did show an increase in
regional ejection fraction and a reduction of the infarct size in the BMC group. Only one
larger study, the ASTAMI (Autologous Stem-Cell Transplantation in Acute Myocardial
Infarction) trial, did not show any benefit.[36] The reason for the failure of the ASTAMI trial
to show a benefit of cell therapy is unclear. However, preclinical work has established a
fundamental role for cell isolation and processing techniques to determine the functional
capacity of progenitor cells used for neovascularization. Because no preclinical functional
testing of the cells used for the ASTAMI trial was performed, it is essentially impossible to
judge the negative outcome of this trial.

Of note, all of the above cited studies used the total population of bone marrow
mononuclear cells, which contain roughly 2 to 3 percent CD34+ cells but also contain SP
cells, mesenchymal cells, and potentially other not yet identified cell populations. However,
patients after acute myo-cardial infarction treated with ex vivo expanded circulating bloodderived EPC in one arm of the TOPCARE-AMI trial showed a similar improvement in heart
function compared to BMCindicating that selected subpopulations might have a similar
capacity for functional repair at least in the acute myocardial infarction setting.[30] Likewise,
the infusion of isolated CD133+ cells, which are enriched for EPC, improved global
ejection fraction in patients with acute myocardial infarction.
The beneficial effects seen in most of the pilot phase I/II studies were confirmed in the
recent so-far-largest double-blind, randomized, multicenter REPAIR-AMI trial.[37] This
study used bone marrow mononuclear cells and demonstrated a significant improvement of
global and regional ejection fraction in the BMC group (+5.5 percentage points) compared
to placebo (+3 percentage points) 4 months after follow-up ( Fig. 29-4 ). End-systolic
volumes significantly increased in the placebo group, but remained unchanged in the BMC
group. Interestingly, although the study was not powered to address a potential benefit on
clinical endpoints, the incidence of the cumulative endpoints death, myocardial infarction,
and rehospitalization for HF was significantly lower in the BMC-treated patients compared
to placebo after 1-year follow up.

FIGURE 29-4 Principal results of the REPAIR-AMI trial. Interaction between baseline left
ventricular ejection fraction and the absolute change in left ventricular ejection fraction (panel A) and
between the timing of intracoronary infusion of BMC or placebo after reperfusion therapy and the
absolute change in left ventricular ejection fraction (panel B). In panel A, the P value for interaction
was determined by analysis of variance. In both panels, the upper and lower edges of each box plot
indicate the 25th and 75th percentiles, the whiskers the 10th and 90th percentiles, the solid
horizontal line the median, and the dashed line the mean. All outliers are shown as individual data
points. In panel B, the P value for interaction was calculated with the use of a general linear model.
The solid line in panel B shows the regression curve for the BMC group, and the dotted line shows the
regression curve for the placebo group. (From Schachinger V, Erbs S, Elsasser A, et al: Intracoronary
bone marrow-derived progenitor cells in acute myocardial infarction. N Engl J Med 355:1210-1221,
2006.)

What variables might influence outcome? The larger number of patients enrolled in the
REPAIR-AMI trial allowed for testing several predefined secondary endpoints to generate
hypotheses for the next generation trials. There was a significant interaction between the
baseline ejection fraction and the improvement seen after BMC therapy. Patients with a
lower ejection fraction (<48.9 percent) showed a significant, threefold higher recovery in
global ejection fraction indicating that patients with more severe myocardial infarction
benefit the most from BMC therapy. Indeed, the beneficial effect on clinical endpoints
was also preferentially observed in those patients with a lower baseline ejection fraction
after myocardial infarction. This observation confirmed the previous results of the
TOPCARE-AMI pilot trial. A second predefined end point addressed the question
whether the timing of BMC delivery affects the outcome. Surprisingly, patients who had
been treated up to 4 days after the myocardial infarction showed no benefit, whereas later
treatment (day 4 to 8) provided an enhanced improvement of ejection fraction during
follow-up. Given that several experimental studies demonstrated that the cells provide a
cytoprotective activity coinciding with a reduction of cardiomyocyte apoptosis, one would
have expected that early timing of cell infusion would have been the most efficient. Based
on the data of the REPAIR-AMI trial, one may speculate that the microenvironment after
acute myocardial infarction changes during the first week after reperfusion, thereby
modulating the homing and/or the subsequent functional activity of the infused cells.[37] It
is well known that ischemia/reperfusion induces a transient change in the expression of
chemoattractive factors such as VEGF and SDF-1, which are known to be essential for
stimulating the recruitment and retention of cells in the tissue. Moreover, the initial edema
formation is followed by a transient invasion of different waves of cells. Therefore, it is
conceivable that cell homing might be best a few days after reperfusion rather than
immediately. Further studies are warranted to prospectively address this question.

Overall, the clinical data available indicate that cell therapy with bone marrow-derived cells
is feasible and safe at least for the follow-up presently available (up to 5 years in the
pioneering studies). None of the studies so far reported an increased incidence of
arrhythmias (as has been seen in myoblast trials). Moreover, restenosis, which was
considered as a potential side effect by progenitor cell-mediated plaque angiogenesis or
plaque inflammation, was increased only in one study using CD133+ cells.[38] Because
CD133+ cells were isolated by using a mouse antibody, one may speculate that the
remaining antibody might have elicited a local proinflammatory reaction, despite the failure
to detect systemic anti-mouse antibodies in the patients. All other studies did not observe an
augmented risk for restenosis; if anything, there was a significantly decreased necessity for
revascularization procedures in the REPAIR-AMI trial.
An important issue is whether the improvement seen during the initial 6 months after cell
therapy is maintained for a prolonged time. Careful evaluation of the 18 months follow-up
data of the BOOST trial indicates that the ejection fraction of the cell therapy group is

maintained from 6 to 18 months of follow-up; however, the difference between the cell
therapy and the control group was no longer statistically significant because of
improvement in ejection fraction in the control group. The small number of patients (30 per
group) may preclude detecting a statistical difference between the two groups. The long
term 2-year follow-up MRI-derived data of the TOPCARE-AMI trial showed that the
ejection fraction is maintained and even further augmented in the treated patients, in parallel
with a sustained reduction in NT-proBNP serum levels, suggesting a beneficial effect of
long term left ventricular remodeling (S. Dimmeler and A. M. Zeiher, unpublished data).
Taken together, these data may provide the rationale to assess the effects of intracoronary
BMC infusion on clinical outcome in a large patient cohort with severe acute myocardial
infarction.

Mobilization Strategies in Acute Myocardial Infarction


The first evidence that cytokine-induced mobilization might be a viable strategy for
augmenting myocardial repair arose from efforts to increase EPC levels for
neovascularization. Vascular endothelial growth factor (VEGF) and granulocyte
macrophage colony-stimulating factor have been shown to augment EPC levels and to
improve peripheral neovascularization.[39] Subsequent experimental reports that bone
marrow-derived hematopoietic stem cells could not only augment vascular repair but also
promote cardiac regeneration stimulated subsequent studies to use the well-studied cytokine
granulocyte colony-stimulating factor (G-CSF) to mobilize bone marrow-derived stem cells
for cardiac repair. Additional experimental studies documented beneficial effects by other
pro-angiogenic growth factors, including stromal cell-derived factor-1 (SDF-1),
angiopoietin-1, placental growth factor, and erythropoietin. Since G-CSF was available for
clinical use, this approach was applied most rapidly in clinical studies. Most studies have
been performed in patients with acute myocardial infarction who were treated with
recombinant G-CSF during the first week after the infarct. The studies have revealed mixed
results ( Table 29-4 ), which is likely due to the different timing of G-CSF application. It
should be noted that, in experimental studies, G-CSF was given either prior to or
simultaneously with the induction of the acute myocardial infarction. In addition,
splenectomized animals were used to limit cell clearance. [40] [41] Whereas two phase I pilot
trials showed a significant improvement of global ejection fraction with G-CSF
mobilization, [42] [43] two recent larger scale randomized, placebo-controlled studies
(STEMMI[44] and REVIVAL[45]) reported no significant influence of G-CSF treatment on
heart function in patients after acute myocardial infarction. The recent MAGIC cell-3-DES
trial,[46] however, suggests that the combination of G-CSF and additional intracoronary
infusion of purified circulating blood-derived progenitor cells may yield better results in
patients with acute myocardial infarction. The overall safety of G-CSF treatment in acute
myocardial infarction has been reviewed critically. Triggered by the report of Kang and
coworkers,[47] who reported a dramatic increase in restenosis after G-CSF treatment for early
patients in the MAGIC trial, further studies have provided a detailed analysis of restenosis
rates after G-CSF treatment. Importantly, none of the subsequent studies have shown that
the short-term treatment with G-CSF had any effect on restenosis. Indeed, a follow-up of
the MAGIC study by Kang and coworkers also confirmed that restenosis rates were not
augmented in patients when treated with drug-eluting stent.[46] The observed increase in
restenosis in the initial MAGIC trial may be partially explained by the study design in

which the initial patients were treated with G-CSF before coronary artery stenting.
However, the reports of an increased incidence of myocardial infarctions and episodes of
angina and arrhythmias during treatment with G-CSF in patients with chronic ischemic
cardiomyopathy should continue to raise some concerns as to whether a G-CSF-induced rise
in leukocyte number may be responsible for plaque growth or destabilization. Accordingly,
in the future, it may be preferable to develop strategies that augment circulating progenitor
cells without the simultaneous induction of massive inflammation.
TABLE 29-4 -- Studies Using Mobilization of Progenitor Cells with Granulocyte ColonyStimulating Factor
Status
Post
Functional
Study
N
MI
Cells
Safety
Assessment
FIRSTLINEAMI[42]

N = 50 1 : 1
rand.

Kuethe, et
al.[43]

STEMMI[44]

G-CSF 10
g/kg, 6 days

safe

Global
contractility

N = 14 versus Acute
MI
N = 9 control

G-CSF 10
g/kg, 7 1
days

safe

Global
contractility

N = 78

Acute
MI

G-CSF 10
g/kg, 6 days

safe

No change

Acute
MI

G-CSF 10
g/kg, 5 days

safe

No change

Rand.,
double-blind,
placebocontrolled

Acute
MI

REVIVAL[45]

N = 114

JAMA 2006

Rand.,
placebo
controlled

Hill, et al.[54]

N = 16

Old MI G-CSF 10
g/kg, 5 days

not safe (2 MI)

No change

N = 16

Old MI G-CSF 10
g/kg, 4 times
10 days
DCM

Occasional episodes
of angina

Six minute
walking

JACC 2005
Huttmann, et
al.[55]

ICM: N = 9
DCM: N = 7

G-CSF with Additional Cell Therapy

Ventricular
fibrillation

distance

Study
MAGIC

N
[47]

N = 10

Status
Post
MI

Cells

Safety

Acute G-CSF CPC


and old (by apheresis)

Functional
Assessment
Global
contractility

Restenosis
(methodological
limitations; see text)
Erbs, et al.[31]

N = 26
Rand.,
placebo
controlled

MAGIC cell3-DES[46]

N = 96
AMI control
(N = 25)

Old MI G-CSF plus


CPC
(cultivation)

safe

Global
contractility

Acute G-CSF plus


and old CPC
MI

safe

AMI: global
contractility

AMI cell (N =
25)
ICM control
(N = 16)

ICM: no
change

ICM cell (N =
16)
AMI = acute myocardial infarction; CPC = circulating progenitor cells; DCM = dilated
cardiomyopathy; G-CSF = granulocyte colony-stimulating factor; ICM = isolated
cardiovascular malformation; MI = myocardial infarction.

Cell Therapy and Cell Mobilization Strategies in Patients with Chronic Heart
Failure
In patients with chronic ischemic heart disease and a prior myocardial infarction, the results
of the initial attempts at cell-based myocardial repair have been more heterogeneous, and
the number of patients that have been treated has been less when compared to acute
myocardial infarction trials. The first cell-based therapy trial used skeletal muscle-derived
progenitor cells, which were directly injected into the scarred region of the left ventricle
during open heart surgery for coronary artery bypass grafting. Global and regional left
ventricular function were significantly and persistently improved. However, the
concomitant coronary artery revascularization confounded the assessment of true benefit in
these studies. Indeed, in patients not undergoing simultaneous revascularization, the
transcatheter injection of myoblasts into the preexisting (5 to 6 year old) postinfarction scar
tissue led to a reduction in the symptoms of HF without any objective evidence of an

improvement in global left ventricular function. Unfortunately, even though extensive


previous animal experiments provided no hint of increased arrhythmias, the enthusiasm for
injecting myoblasts into scar tissue for cardiac repair was dampened by development of lifethreatening arrhythmias in the patients who were treated.[48] Mechanistically, these
arrhythmias may be related to the lack of electrical coupling of skeletal muscle to
neighboring cardiac myocytes or, alternatively, it may be contingent on coupling by the few
hybrid cells formed by fusion with adjacent cardiac myocytes, which generate spatially
heterogeneous calcium transients. Therefore, currently, the implantation of skeletal
myoblasts requires the implantation of an implantable cardioverter defibrillator as a
mandatory adjunct to therapy.
Bone marrow-derived progenitor cells have been em-ployed in several smaller,
nonrandomized trials for chronic ischemic HF using different strategies for cell delivery.
Three studies have used electromechanical mapping of the left ventricular endocardial
surface to identify sites for injecting cells into areas of myocardial hibernation. [49] [50] Each
of these studies has shown a significant increase in global left ventricular ejection fraction
associated with decreased end-systolic volumes, as well as an improvement in exercise
capacity. Although this functional improve-ment might be secondary to an improved blood
supply to hibernating cardiomyocytes, it is also conceivable that hibernating myocardium
may provide a more favorable microenvironment for the survival/engraftment of the
injected cells when compared to an injection in scar tissue. Others have used a surgical
approach to inject bone marrow-derived cells during coronary artery bypass surgery
(CABG). Again, an increase in ejection fraction was documented. Although the effect of
CABG and BMC cannot be dissociated in these pilot trials, a recent study showed a more
profound effect in patients being treated with CABG and cells in comparison to CABG or
cells alone.[51] Finally, encouraging preliminary results were recently reported in a
controlled safety trial of patients with normal left ventricular ejection fraction, but persistent
angina refractory to revascularization procedures (D. Losordo, personal communication). In
this trial, blood-derived CD34+ cells were collected following G-CSF mobilization and
directly injected into underperfused left ventricular areas by catheter-based
electromechanical mapping.

Three published studies addressed the possibility to use intracoronary delivery of BMC by
a balloon catheter. The IACT study tested the feasibility of BMC infusion in patients with
chronic HF and demonstrated a substantial increase in ejection fraction (+15 percent) in
patients with healed (>3 months old) myocardial infarction.[52] Smaller, but significant,
improvements were also seen in the randomized controlled trials by Erbs and colleagues
and the TOPCARE-CHF study. Erbs and colleagues infused G-CSF mobilized, ex vivo
cultivated endothelial progenitor cells in a recanalized coronary artery.[31] Coronary flow
reserve in response to adenosine and global ejection fraction were improved in the celltreated patients compared to recanalization without cell therapy. A smaller, but
significant, improvement was also observed in the TOPCARE-CHF study.[53]
Interestingly, this study was the first to examine a direct side-by-side comparison of two
different cell types in patients with old myocardial infarctions. In this patient cohort,
BMCs were shown to be significantly better as compared to circulating progenitor cells.

This is in contrast to the TOPCARE-AMI trial, wherein BMC and EPC showed a similar
effectiveness in acute myocardial infarction patients.[30] The reason for this discrepancy is
unclear. One may speculate that the number and function of circulating cells is further
impaired in HF patients and that an additional mobilization step is required to yield a
sufficiently high number of functionally active cells (as done by Erbs and colleagues).
Another potential explanation may relate to the combination of a lower number of EPC
applied (22 10[6] compared to 205 10[6] BMC) and/or a reduced homing capacity in the
chronic setting, which might limit the efficiency of EPC.

Finally, as discussed extensively earlier, different cell types may activate different
mechanisms which may be more or less beneficial in acute versus chronic ischemic HF.
Mobilization of progenitor cells with G-CSF without intracoronary reinfusion did not result
in any measurable benefit on left ventricular function, but was associated with adverse
coronary events in two studies. [54] [55]

Future Perspectives in Myocardial Repair and Regeneration


Cell transplantation has been performed days, months, or years following myocardial
infarction. In acute myocardial infarction, the established safety and proof-of-concept
studies provide a cogent rationale for larger, randomized trials addressing the question
whether cellular therapy aimed at cardiac repair not only improves pump function, but also
reduces mortality and morbidity. Several open questions are likely to be answered in the
future: (1) what is the optimal time of delivery after acute myocardial infarction? (2) Is
there a dose response relationship? and (3) how do different cell types compare? One of the
most urgent questions in basic science, to elucidate the mechanism by which
stem/progenitor cells achieve a functional improvement, is difficult to test in the clinical
scenario. Although clinicians can measure flow reserve and heart function, the underlying
detailed mechanism cannot be determined with an ethically applicable technology in the
near future. In chronic ischemic HF, a superimposed question is whether identifying
hibernating myocardium to direct cell therapy is essential to an effective outcome. For
established scar tissue late in the disease, specific strategies might be needed. The treatment
of nonischemic heart disease is not yet addressed. An overview of currently ongoing clinical
trials of progenitor cell application for cardiac regeneration can be viewed at
www.ClinicalTrials.gov .

WHAT IS THE BEST CELL TYPE FOR CARDIAC REPAIR?


Direct side by side comparison using different cell types is rare particularly in the clinical
setting. Clearly, bone marrow-derived cells have set the stage and have provided
beneficial effects in various studies. However, the extent to which ejection fraction is
improved, particularly in chronic HF, is limited. Therefore, additional cell types will enter
the clinical arena: fat tissue-derived multipotent stem cells, multipotential cells from bone
marrow or skeletal muscle (minuscule subpopulations, distinct from the unfractionated
bone marrow and the myoblasts in current trials), somatic stem cells from placental cord
blood, adipose tissue-derived stem cells and cardiac-resident progenitor cells that have a

heightened predisposition to adopt the cardiac muscle fate are on the way for potential
clinical application. However, whether the experimentally suggested promise of
augmented cardiac myogenesis will translate into enhanced contractile function, when
applying cells in patients with chronic HF, is unknown.
More complex and challenging are a series of pathobiological concerns, sending the
scientific community from bedside to bench and back again. As long as a patient's own
cells are used in the autologous setting, certain of those cells may be unsatisfactoryin
their nave and unmanipulated stateprompting systematic dissection of each step in
progenitor cell function. Cell enhancement strategies to improve patient-derived cells by
pretreatment with small molecule or genetic modification may contribute to an augmented
recruitment as well as in the future may enhance differentiation or other beneficial
functions.

Clearly, the use of stem/progenitor cells for cardiac repair is currently not at a stage to be
used in routine clinical practice. Despite a wealth of experimental and clinical data
suggesting feasibility, safety, and even early clinical efficacy in patients with acute
myocardial infarction, progression to widespread clinical application of progenitor cell
administration to promote functional cardiac regeneration must be balanced against the
inherent risk of testing a novel therapy. As such, attempts of regenerative therapeutic
interventions in patients with significant cardiac dysfunction should proceed in controlled
trials with the utmost rigorous scientific and ethical standards, paralleled by further
extensive in vitro and animal studies. Such a strategy will not only maximize patient safety,
which is of paramount interest, but will also generate reciprocal insights into mechanisms
and potential shortcomings of cell-based therapies aiming at functional cardiac
regeneration. Specific attention should be given to the processing of the cells and to
ascertain their functionality for regenerative purposes prior to initiating their clinical
application. The promise of functional cardiac regeneration by cell-based therapies offers
novel opportunities to address the large, unmet clinical need of treating patients with severe
cardiac dysfunction.
Copyright 2007 Elsevier Inc. All rights reserved. - www.mdconsult.com

Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.


Copyright 2007 Saunders, An Imprint of Elsevier

GENE THERAPY
Gene therapy represents another emerging therapeutic approach for the treatment of HF.
Improvements in gene transfer vectors and gene transfer methodology have enabled
recombinant genes to be expressed at robust levels in cardiac myocytes.[56] Further, recent
advances in the field of RNA interference (RNAi) suggest that it may also be possible to use
gene therapy to silence key pathogenetic genes or pathways that are activated in the
failing heart. [57] [58]
Three elements are necessary for the successful clinical application of any gene therapeutic
approach.[59] First a vector or packaging system is necessary to deliver the genetic material.

Only a few of the currently available viral vectors are able to achieve efficient, high-level
transgene expression in postmitotic cells such as cardiac myocytes. These include
recombinant adenoviruses, adeno-associated viruses, and possibly lentivirus. Recombinant
adenoviruses have been used most commonly because of their ability to package large
DNA constructs, as well as their ability to transduce nonreplicating cells. However, the
robust immune response these vectors evoke suggests that clinical applications will likely
require other vectors or further-refined adenoviral systems. Second, the vector needs to be
adequately delivered to the affected tissue(s). The feasibility of in vivo cardiac gene transfer
by viral vectors has been consistently demonstrated in experimental studies. As illustrated
in Figure 29-5 , a number of mechanical approaches have been used to achieve cardiac gene
transfer. Intracoronary catheter delivery of an adenovirus encoding the reporter gene betagalactosidase achieved transduction of approximately 30 percent of the cardiac myocytes in
the distribution of the injected coronary artery. Direct injection of adenovirus into the
ventricular wall using an epicardial approach has also been shown to induce significant
expression of reporter constructs; however, the expression was focal and the needle
injections within the heart resulted in myocardial damage. Intramyocardial delivery of
adenovirus using an intraventricular approach with retro-infusion of coronary veins has also
been used in larger animals, yielding regional areas of transduction. Injection of an
adenovirus carrying beta-galactosidase into the pericardial sac transduced only the
pericardial cell layers.[59] The third element that is necessary for a successful gene
therapeutic approach is to identify the appropriate gene targets to modulate. Table 29-5
summarizes potential targets for gene therapy in HF based on experimental studies. The
major promising targets for gene transfer have been those genes that regulate the betaadrenergic receptor (AR) signaling pathway and genes that regulate calcium handling in the
heart.[58]

FIGURE 29-5 Different techniques for in vivo cardiac gene transfer. A, Coronary perfusion. B,
Intramyocardial injection. C, Pericardial injection. D, Aortic clamping. E, Cross-clamping of the aorta
and pulmonary artery. IVC = inferior vena cava; SVC = superior vena cava. (Modified from Hajjar
RJ, del Monte F, Matsui T, Rosenzweig A: Prospects for gene therapy for heart failure. Circ Res
86:616-621, 2000.)

TABLE 29-5 -- Potential Therapeutic Targets for Gene Therapy in Heart Failure
Target
Function
Beta-adrenergic receptor Inhibits phosphorylation of -adrenergic receptor thus preventing its

Target

Function

kinase inhibitor
(ARKct)

desensitization

Adenylyl cyclase (AC)

Synthesizes cAMP to activate PKA, which then phosphorylates


substrates to regulate calcium handling

Sarcoplasmic reticulum Responsible for the reuptake of calcium from cytoplasm into the SR
Ca2+ ATPase (SERCA2) lumen. Critical determinant of both relaxation and contractility via
calcium sequestration into SR and via controlling SR calcium
loading, respectively
Phospholamban (PLN)

Inhibits SERCA2, inactivated by phosphorylation by PKA and


CaMKII

Parvalbumin (Parv)

Rapidly removes calcium in myofilaments, naturally abundant in


skeletal muscle (not cardiac); results in enhanced relaxation

S100 protein

A calcium binding protein, a positive inotropic regulator of cardiac


function that enhances calcium cycling and cardiac contractile
performance in vitro and in vivo

CaMKII = Ca2+/calmodulin-dependent protein kinase; PKA = protein kinase A; SR =


sarcoplasmic reticulum.

As noted in Chap. 21 , the beta-AR signaling pathway is critical for modulating myocardial
contractility. Studies have shown that alterations in the myocardial beta-AR both precede
and accompany the development of HF in humans, including downregulation of the betaARs, functional uncoupling of beta-ARs from second messenger systems, and increased
levels of inhibitory G-proteins that blunt beta-AR signaling (see also Chap. 22 ).[60] Indeed,
transgenic mice with cardiac restricted overexpression of the beta2-AR have enhanced
myocardial contractility.[61] However, as noted in Chap. 22 , excessive and/or sustained
stimulation of the beta-AR signaling can also lead to activation of maladaptive signaling
pathways in the heart (e.g., activation of the fetal gene program), as well as myocyte death
through both necrosis and apoptosis. For example, transgenic mice that overexpress the
beta1-AR develop a dilated cardiomyopathy.[62] Viewed together, these types of
experimental studies have generated considerable interest in using selective genetic
approaches to modulate beta-AR signaling pathways in HF models. Thus far, adenoviralmediated gene transfer of the human beta2-AR resulted in an improvement in contractility in
myocytes isolated from a rabbit model of HF,[59] as well as in myocytes from failing
hearts.[58] Similarly, adenoviral-mediated gene transfer of a peptide inhibitor of beta-AR
kinase (see Chaps. 21 and 22) resulted in restoration of beta-AR signaling, increased cyclic
AMP, and reversal of ventricular dysfunction in rabbit HF models.[59]

Enhancement of myocardial contractility through manipulation of intracellular calcium


signaling has garnered considerable enthusiasm as a potential target for gene therapy in HF.
Several studies suggest that functional suppression of sarcoplasmic reticulum Ca2+-ATPase
(SERCA2a) activity, or an absolute reduction in the amount of SERCA2a protein, may
contribute significantly to the abnormalities in Ca2+ handling and myocardial contraction
observed in failing hearts (see Chap. 22) . In an animal model of pressure-overload
hypertrophy that transitions to failure, overexpression of SERCA2a by gene transfer in vivo
restored both systolic and diastolic function to normal levels.[63] Similarly, overexpression of
SERCA2a through gene targeting resulted in normalization of LV volumes, improved
energetics, and prolonged survival in an experimental model of pressure-overload
hypertrophy.[64] Overexpression of an antisense phospholamban construct or a dominantnegative mutant of phospholamban (see Chap. 21) has recently been shown to enhance
SERCA2a activity, consistent with the prior observation that genetic ablation of
phospholamban prevents the functional abnormalities otherwise seen in a mouse model of
dilated cardiomyopathy.[59] Similar beneficial effects on cardiac contractility, including
normalized calcium handling and enhanced SERCA2a activity, have been observed in
experimental and human HF models following gene transfer of S100A1 (a calcium binding
protein).[65]
In addition to modulating myocardial contractility, gene therapeutic approaches may also be
used to target myoycte viability or fibroblast phenotype. Morphological and biological
markers of programmed cell death or apoptosis have been identified in human HF,
suggesting that these pathways may contribute to cardiomyocyte loss and cardiac
dysfunction in HF (see Chap. 22) . The potential to block cardiomyocyte apoptosis through
somatic gene transfer is, therefore, another area of ongoing investigation.[66] Also, the ability
to modulate fibroblast phenotype has been explored in experimental models of myocardial
infarction, wherein gene-mediated transfer of myogenic determination gene, MyoD, has
been used to transduce cardiac fibroblasts into functional skeletal muscle cells with the
intent of reducing infarct size/expansion within the border zones of the infarct.[67]

Future Perspectives in Gene Therapy


Gene transfer strategies that result in improvements in myocardial contractility and/or
cardiac remodeling appear promising in experimental models of HF. However, it bears
emphasis that considerable work remains to be done with respect to improvements in vector
technology, methods for cardiac gene delivery, and perhaps most importantly,
understanding what gene targets are safe to target in clinical trials in HF patients. To date,
there are no clinical trial data on gene therapy in patients with HF; however, small clinical
trials targeting SERCA2 are being planned.
Copyright 2007 Elsevier Inc. All rights reserved. - www.mdconsult.com

Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.


Copyright 2007 Saunders, An Imprint of Elsevier

PHARMACOLOGICAL STRATEGIES
Pharmacogenetics

As discussed in Chap. 6 , the field pharmacogenetics attempts to define common gene


polymorphisms, or sets of polymorphisms, that underlie variability in drug action. Given the
tremendous heterogeneity that exists in HF pa-tients, it is likely that genetic variations play
a significant role in determining drug metabolism, disposition, and functional activity in HF
patients. As noted, current HF practice guidelines (see Heart Failure Guidelines)
recommend titrating ACEIs, angiotensin receptor blockers, aldosterone antagonists, and
beta blockers to doses that have been shown to be beneficial in clinical trials (see Table 259 ). Although this approach tends to work well for most patients, it has two major
shortcomings, the most obvious of which is that basing drug dosing on the doses selected in
clinical trials does not allow for dose optimization in patients who may metabolize and/or
distribute drug differently. The second problem is that clinical trials are generally designed
to yield binary results. That is, a drug under investigation is either deemed beneficial or
not beneficial because the patients in the treatment arm have, or have not, reached a
prespecified endpoint (e.g., death or hospitalization). A beneficial effect in a positive
clinical trial implies that all patients will receive the same degree of benefit from the drug
that is given. However, a more likely outcome is that a given therapy will have a markedly
positive impact for some patients, a more modest effect in others, and may be completely
ineffective or perhaps even harmful in a smaller group of treated patients. Thus, even
though a drug is deemed beneficial in a clinical trial, there is no guarantee that an individual
patient will benefit from the treatment. For example, beta blockers have been shown
consistently to reduce the risk of death in HF patients by approximately 35 percent (see Fig.
25-16 ). However, clinical trials have also shown that beta blockers will need to be
discontinued in 8 to 25 percent of HF patients because of significant adverse effects,
including worsening HF.[68] Recent advances in the field of pharmacogenetics suggest that a
careful analysis of underlying gene polymorphisms within a given patient may enable
clinicians to develop personalized therapeutic regimens for HF patients. Given the central
role of the renin angiotensin-aldosterone (RAS) and adrenergic systems in the
pathophysiology (see Chap. 22) and treatment of HF (see Chap. 25) it is perhaps not
surprising that polymorphisms in the genes that regulate these pathways appear to influence
the therapeutic efficacy of ACEIs and/or beta blockers. Table 29-6 provides an overview of
the major genetic variations in these pathways and the proposed functional impact of these
polymorphisms, as well as how these genetic polymorphisms influence traditional
pharmacotherapeutic approaches in HF.
TABLE 29-6 -- Effect of Gene Polymorphisms on the Pharmacological Treatment of Heart
Failure
Impact on
Pharmacological
Pathway/Gene Polymorphism Functional Impact
Therapy
Renin-Angiotensin-Aldosterone
ACE

287 bp insertion DD genotype has increased


(I) or deletion
ACE activity and worse
(D) in intron 16 clinical outcomes in some (but
not all studies)

Use of beta blockers and


ACEIs attenuates adverse
outcomes of DD genotype
but has no effect on II/ID

Pathway/Gene

Polymorphism

Functional Impact

Impact on
Pharmacological
Therapy
genotypes; II/ID genotype
predicts reverse LV
remodeling in response to
spironolactone

Angiotensinogen Methionine
Increased angiotensinogen
(Met) to
levels with HTN
threonine (Thr)
switch at aa 235

Modest risk of
hypertension in whites;
effect on drug
responsiveness in HF not
known

Aldosterone
synthase

TT genotype associated
with greater impact of
fixed combination of
isosorbide dinitrate and
hydralazine on the eventfree survival in the AHeFT trial

C to T transition -344C allele associated with


at position -344 higher aldosterone levels
(T/C)

Adrenergic Nervous System


Beta1-AR

Arginine (Arg), Arg 389 polymorphism has


glycine (Gly)
increased adenylyl cyclase
switch at aa 389 activity in response to agonist 3
greater than Gly389 variant.

Arg389Arg genotype
greatest improvement in
EF with beta blockers,
and improved mortality
with bucindolol treatment
in BEST

Beta1-AR

Serine (Ser),
glycine (Gly)
switch at aa 49

Ser49Ser genotype
requires higher doses of
beta blocker to achieve a
mortality benefit

Beta2-AR

Threonine (Thr) Ile164 beta2-AR has decreased


to isoleucine Ile affinity for catecholamine
switch at aa 164 binding, decreased basal and
epinephrine-stimulated
adenylyl cyclase activity, and
impaired agonist-promoted
sequestration; Ile164 transgenic
mice display depressed resting
and agonist-stimulated
contractile function in vivo
compared with Thr164 mice

In vitro the Gly49 variant


shows decreased receptor
expression compared with
Ser49 variant after exposure to
isoproterenol (24 hours)

Associated with decreased


VO2 max and worse HF
outcomes; effect on drug
responsiveness in HF not
known

Pathway/Gene

Polymorphism

Functional Impact

Alpha2C-AR

Alpha2C Del322 Decreased NE uptake


325

Impact on
Pharmacological
Therapy
Increased likelihood of
developing HF in patients
with the beta1-AR Arg389
polymorphism; effect on
drug responsiveness in HF
not known

ACE = angiotensin-converting enzyme; AR = adrenergic receptor; HF = heart failure; HTN


= hypertension; NE = norepinephrine.

One of the most widely studied genetic variants is the ACE insertion/deletion
polymorphism (I/D) that involves a 287-base pair insertion or deletion within intron 16 of
the ACE gene. Although the clinical significance of this polymorphism remains
controversial, the physiological association with ACE enzymatic activity has consistently
been demonstrated. Studies have shown that individuals with the DD genotype have the
highest ACE activity and angiotensin II levels, heterozygotes (I/D) have intermediate levels,
and individuals who are homozygous for the I allele (I/I) have the lowest levels of ACE
activity. The relationship of ACE I/D has been explored in relation to numerous conditions
including atherosclerosis, myocardial infarction, left ventricular hypertrophy, hypertrophic
cardiomyopathy, and HF. Although the current weight of evidence does not allow for
definitive conclusions to be made with respect to the overall contribution of the ACE I/D
polymorphism to the clinical outcome in these conditions, there is growing evidence that the
ACE I/D polymorphism may predict drug responsiveness to both beta blockers and ACEIs
in HF patients. In one study of patients with chronic HF, the ACE DD polymorphism was
significantly associated with death or the need for transplantation when compared to
patients with II or ID genotypes. Within the ACE DD group, patients treated with beta
blockers had significantly improved transplant-free survival when compared to patients not
receiving beta blocker therapy, whereas beta blocker treatment had no effect in clinical
outcomes in the II or ID groups.[69] In a similar study, patients with the DD genotype had
better clinical outcomes when receiving high-dose ACEI therapy when compared to lowdose ACEI therapy, whereas the ACE dose had no effect on clinical outcomes in patients
with either the II or ID genotypes. In this study, the regimen of high-dose ACE inhibitors
and beta blockers had the greatest impact on transplant-free survival in patients with the DD
variant.[69] Taken together these studies suggest a differential clinical response to standard
HF therapy based on the ACE I/D polymorphism.
Although the impact of genetic heterogeneity on HF outcomes has been extensively studied
in predominantly white cohorts, few studies have investigated the impact of genomic
variation in blacks. In a genetic substudy of the African-Americans in Heart Failure (A-

HeFT) trial (see Chap. 25) , a single nucleotide polymorphism within the promoter region of
the aldosterone synthase gene (C to T transition at position -344) was shown to predict
responsiveness to the fixed combination of hydralazine isosorbide dinitrate (see Chap. 25)
.[70] In A-HeFT treatment with the fixed combination of hydralazine isosorbide dinitrate was
associated with a markedly improved clinical outcome (mortality, HF hospitalization, and
change in quality of life at 6 months) in the TT homozygotes, but had no significant impact
among subjects with the -344C allelesuggesting that genetic variations in aldosterone
production may play an important role in disease progression in blacks with HF.
Polymorphisms that affect the function of beta- or alpha-adrenergic receptors may also
influence the pharmacological response in HF patients (see Table 29-6 ). Patients with a
common polymorphism of the beta1-adrenergic receptor (AR) that results in either an
arginine (Arg) or glycine (Gly) substitution at amino acid position 389 have different
clinical responses to beta blockers. In the Bucindolol Evaluation of Survival Trial (BEST),
bucindolol-treated patients who were homozygous for the Arg389 polymorphism
(Arg389Arg) had improved clinical outcomes when compared to glycine carriers
(Arg389Gly and Gly389Gly) who were treated with bucindolol ( Fig. 29-6 ), suggesting that
the therapeutic response to beta blockers differs by genotype.[71] The Arg389Arg genotype
was also associated with significantly greater reductions in LV end-diastolic and endsystolic diameters following treatment with beta blockers when compared to identically
treated Gly389 carriers.[72] The alpha2c-adrenergic receptor inhibits norepinephrine release at
cardiac presynaptic nerve endings through a negative feedback mechanism. The deletion of
four consecutive amino acids in (aa 322-325) in the alpha2c-adrenergic receptor results in
loss of normal synaptic autoinhibitory feedback mechanism and enhanced presynaptic
release of norepinephrine. There appears to be an increased risk of developing HF ( Fig. 297 ) when the alpha2cDel322-325 and the Arg389 beta1-AR polymorphism are both present
(i.e., a diplotype).[73] Although the impact of the alpha2cDel322-325 and Arg389 beta1-AR
synergism on beta blocker responsiveness is not known, it is likely that patients with this
diplotype may have increased responsiveness to beta blockers, based on what has been
reported for the Arg389 polymorphism. In addition to contributing to the functional
response to beta blockers, genetic polymorphisms that affect drug metabolism may also
influence the therapeutic response to beta blockers. For example, genetic variants in the
cytochrome P450 (CYP) 2D6 gene have a marked effect on plasma concentrations of
metoprolol and carvedilol. In subjects with a nonfunctional CYP2D6 enzyme (poor
metabolizers), the peak plasma concentration of metoprolol is sixfold higher than in
subjects with a normally functioning enzyme.[68]

FIGURE 29-6 Kaplan-Meier analysis of endpoints in BEST trial stratified by treatment (placebo or
bucindolol) and b1AR genotype. A, For survival, Arg homozygotes had an HR = 0.62, 95 percent CI
= 0.40-0.96, p = 0.03. In contrast, for 1-Gly-389 carriers, the HR = 0.90, 95 percent CI = 0.62-1.30, p
= 0.57. B, Graphical representation of HRs and CIs by bucindolol and placebo is shown. Hosp,
hospitalization. (From Liggett SB, Mialet-Perez J, Thaneemit-Chen S, et al: A polymorphism within a
conserved b1-adrenergic receptor motif alters cardiac function and beta blocker response in human
heart failure. Proc Natl Acad Sci U S A 103:11288-11293, 2006.)

FIGURE 29-7 Basis of the hypothesis that the a2cDel322-325 and b1Arg389 receptors act
synergistically as risk factors for heart failure. The a2c-adrenergic receptor (along with the a2aadrenergic receptor) inhibits norepinephrine release at cardiac presynaptic nerve endings through
negative feedback. The presence of the dysfunctional a2cDel322-325 receptor would be expected to
result in enhanced norepinephrine release. The b1-adrenergic receptor is the receptor for
norepinephrine on the cardiomyocyte, and the presence of the hyperfunctional b1Arg389 receptor
would be expected to increase contractile response at the myocytes. The combination of increased
norepinephrine release and increased responsiveness of the receptor was hypothesized to be a risk
factor for heart failure. (From Small KM, Wagoner LE, Levin AM, et al: Synergistic polymorphisms
of b1 and a2c-adrenergic receptors and the risk of congestive heart failure. N Engl J Med 347:1135,
2002.)

Future Perspectives in Pharmacogenetics


Although previous studies have explored the role of single gene polymorphisms with the
renin angiotensin-aldosterone and adrenergic systems in HF patients, it is likely that future
investigations will explore the functional role of multiple genetic variations within a given
pathway (i.e., polygenic phenotypes). Given the wealth of data emerging from the Human
Genome Project and Human Haplotype Mapping Program (HapMap) it will soon be
possible to analyze complex phenotypes in relation to drug responsiveness in individual HF
patients to better predict outcomes. This statement notwithstanding, it bears emphasis that
the concept of personalizing therapeutic approaches in HF based on genetic background is
far from fully developed, and will need to be carefully evaluated prospectively in suitable
patient populations before this type of information can be used to guide clinical practice.

Metabolic Modulation

Optimization of myocardial energy utilization represents another unique approach for the
treatment of HF. As noted in Chap. 22 , myocardial high-energy phosphate concentrations
are decreased in experimental and clinical HF, leading to the suggestion that the failing
heart is energy starved. In the normal heart, free fatty acids are the preferred fuel for the
heart, producing roughly 4 times the ATP per mole of substrate utilized when compared to
glucose. However, fatty acid oxidation is less efficient than glucose oxidation, requiring 10
to 12 percent more oxygen consumption to produce equivalent amounts of ATP. In
addition, high rates of fatty acid oxidation are also associated with uncoupling of oxidative
phosphorylation, an oxygen-wasting phenomenon, leading to an even greater consumption
of molecular oxidation. Under conditions wherein oxygen is the limiting substrate, such as
occurs in the failing heart (see Chap. 22) , glycolysis becomes the more efficient pathway,
requiring less oxygen compared with oxidation of free fatty acid. Fatty acid oxidation is
physiologically regulated at several levels, including the concentration of circulating free
fatty acid substrate, at the level of entry into the mitochondrion, and by the activity of
several of the mitochondrial matrix enzymes that comprise the beta-oxidation pathway.[74]
On the other hand, the rate of glucose oxidation is regulated primarily, although not
exclusively, by the rate of fatty acid oxidation which inhibits the pyruvate dehydrogenase
complex (PDH), the activity of which is rate limiting for glucose oxidation ( Fig. 29-8A ).
Inhibition of pyruvate dehydrogenase can lead to increased glucose utilization through
conversion of pyruvate to lactate, resulting in progressive tissue acidosis, and impaired
myocyte contractility (see Fig. 29-8 ). From a theoretical perspective, shifting energy
utilization from free fatty acids to glucose would optimize metabolic efficiency, reverse
abnormalities in the cellular milieu, and improve cardiac function (see Fig. 29-8B ).

FIGURE 29-8 Metabolism of free fatty acids and glucose. A, Metabolic pathway for glucose
metabolism and fatty acid oxidation; B, Effects switching metabolism from fatty acid beta-oxidation
to glucose oxidation (under conditions wherein oxygen supply is rate limiting) using partial inhibitors
of fatty acid oxidation (pFOX).

The prototype partial inhibitors of fatty acid oxidation (pFOX), etomoxir, oxfenicine, and
perhexiline, act by inhibiting carnitine palmitoyltransferase I (CPT I), the gatekeeper of
fatty acid entry to the mitochondrion (see Fig. 29-8A ). These agents shift energy utilization
from free fatty acids to glucose by decreasing oxidation of free fatty acids. However,

because there is no apparent feedback from CPT I activity to sarcolemmal fatty acid import,
CPT I inhibitors can lead to accumulation of unmetabolized lipids in cardiac myocytes,
which may lead to lipotoxicity-induced cardiac myocyte cell death. Etomoxir is an oxirane
carboxylic acid derivative that indirectly promotes increased glucose oxidation through
inhibition of CPT I. In an open-label, uncontrolled trial conducted in 10 patients with
NYHA class II-III HF, treatment with etomoxir for 3 months was associated with a
significant improvement in LVEF, cardiac output at peak exercise, and clinical status.[75]
Subsequent phase II studies with etomoxir were halted because the compound did have the
expected efficacy in the treatment of HF (data obtained from MediGene 2002 Annual
Report [March 26, 2003]). Although oxfenicine was shown to be beneficial in the canine
rapid pacing model of HF, in other animal models treatment with oxfenicine resulted in a
dose-related increase in cardiac mass, as well as an increase in liver and kidney weights.
Perhexiline is currently in use clinically as an anti-anginal agent. Although there were early
reports of hepatotoxicity with this agent, hepatotoxicity occurred in patients with a genetic
variant of a cytochrome P450 enzyme (slow hydroxylation), which resulted in drug
accumulation, as well as accumulation of phospholipids in the liver and nerves. The risk of
toxic effects is virtually eliminated by maintaining plasma concentrations between 150 and
600 ng/ml, at which levels the drug still remains effective.[75] Perhexiline has shown promise
as adjunctive therapy for HF in a small short-term randomized double-blind clinical trial in
patients with ischemic and nonischemic cardiomyopathy. In this study, 8 weeks of treatment
with perhexiline resulted in an increase in the combined primary endpoint of peak oxygen
uptake and LVEF, and an improvement in quality of life (Minnesota Living with Heart
Failure Questionnaire). Importantly, maximum oxygen uptake increased significantly in
both the ischemic and nonischemic groups, suggesting that the benefit of perhexiline was
not entirely anti-ischemic.[76] Although there remains some optimism that CPT I inhibitors
can be used as adjunctive therapy in HF, other pFOX inhibitors may have fewer side
effects.
The pFOX inhibitors trimetazidine and ranolazine were also originally developed as antianginal agents. Trimetazidine is a piperazine compound that has been widely used outside
of the United States as an anti-anginal agent. Trimetazidine has no discernible vasodilator
properties at rest or during dynamic exercise, and has a very favorable side-effect profile.
The exact mechanism of trimetazidine is not known, but it appears to work, at least in part,
through inhibition of long-chain 3-ketoacyl coenzyme A thiolase, a crucial enzyme in the
terminal steps of mitochondrial beta-oxidation. Several small clinical trials have shown
improvements in ejection performance, reverse cardiac remodeling, and improvement in
NYHA functional class with trimetazidine.[75]

Trimetazidine has been evaluated in a number of small clinical trials in patients with both
ischemic and nonischemic cardiomyopathy. [74] [75] Two months of treatment with
trimetazidine resulted in significant improvement in LVEF at rest and enhanced LV wall
motion during a dobutamine stress test compared with placebo in NYHA class II and III
HF patients.[74] In two recent small clinical studies trimetazidine was shown to improve
systolic LV function in patients with diabetes and ischemic cardiomyopathy when
compared with placebo. [74] [77] In contrast, another study, which assessed the effects of

trimetazidine in patients with HF who were diabetic, demonstrated no significant effect on


exercise capacity and only minor effects on LV systolic function.[75] In a study that
specifically enrolled elderly patients with CAD and LVEF <50 percent, the group that
received 6 months of trimetazidine on top of standard therapy showed a significantly
greater improvement in LVEF (7 percent), as well as smaller LV end-diastolic and
systolic dimensions. In addition, the trimetazidine group had improved NYHA functional
class and quality-of-life scores (Minnesota Living with Heart Failure Questionnaire).
These findings have been confirmed in recent larger trials with longer term follow-up (18
to 24 months), which have also shown improvements in LVEF, reduction in LV volumes,
and improvement in NYHA functional class in patients with ischemic cardiomyopathy
(LVEF <50 percent).[75] Given the anti-anginal effects of trimetazidine, it is perhaps not
surprising that this agent led to improvements in LV function and NYHA functional class
in patients with ischemic cardiomyopathy. However, a recent study with trimetazidine
also included patients with nonischemic cardiomyopathy, and showed similar increases in
LVEF, reductions in LV end-systolic volume, and similar trends for improved quality of
life and exercise capacity in both the ischemic and nonischemic groups.[78] Thus, it
appears that trimetazidine has both functional and physiological benefits regardless of the
HF etiology.

Ranolazine (Ranexa) is a novel anti-ischemic drug that prolongs the QT interval, and is the
first FDA-approved pFOX inhibitor for the treatment of angina. The principal mechanism
of action for this drug as an antianginal remains controversial, although recent studies
suggest that the anti-anginal effects of ranolazine may be related (see Chap. 54) to
decreased sodium entry into cells by inhibiting the rapid component of the delayed rectifier
K+ current (Ikr[BL3] [see Chap. 31 ]). Ranolazine also increases the activity of pyruvate
decarboxylase, a key regulator of glucose metabolism, most likely due to loss of inhibition
of the end-products of the beta-oxidation (NADH, acetyl-CoA). No clinical trials have yet
been reported utilizing ranolazine in patients with cardiomyopathy. However, animal
studies employing a canine model of chronic HF induced by microembolization have shown
that, acutely, ranolazine significantly increased LVEF, peak +dp/dt, stroke volume, and
mechanical efficiency.[79]

Future Perspectives in Metabolic Modulation


Switching substrate metabolism using pFOX inhibitors represents an attractive therapeutic
target in patients with HF. Conceptually, another means to switch substrate metabolism
would be to directly stimulate glucose uptake or pyruvate oxidation; however,
pharmacological agents are not currently available for the chronic inhibition of this
pathway, nor activation of glucose transport or glycolysis. Although the use of pFOX
inhibitors appears promising, it bears emphasis that all of the clinical studies to date are
small and have design flaws that are inherent to early phase clinical trialsnot the least of
which is a lack of long-term outcomes data. Accordingly, additional studies will be required
before this therapy can be used in HF patients.

Immunomodulation

Experimental and clinical studies suggest that inflammation plays a role in the pathogenesis
of HF ( Chap. 22 ). Over the past decade a variety of different anti-inflammatory strategies
have been tried in small clinical trials in patients with chronic HF ( Fig. 29-9 ; reviewed in
references 80, 81 [80] [81]). Thus far, two different anti-inflammatory approaches have not
favorably impacted morbidity and mortality when examined in phase III clinical trials. The
first trial used a targeted anti-cytokine approach with a tumor necrosis factor (TNF)
antagonist (RENEWAL [Randomized Etanercept Worldwide Evaluation]),[82] whereas the
second trial employed intramuscular injections of autologous blood (ACCLAIM [Advanced
Chronic Heart Failure Clinical Assessment of Immune Modulation Therapy]) that had been
subjected to oxidative stress ex vivo using a proprietary device (Celacade).[83] Despite these
initial disappointing results, there are several emerging antiinflammatory approaches that
are currently being evaluated in HF patients. One of the more promising approaches is the
use of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins)
in patients with chronic HF.

FIGURE 29-9 Therapeutic strategies for antagonizing proinflammatory mediators. TNF gene
transcription is mediated, in part, by activation of NF-kB. Agents that increase intracellular levels of
cAMP (1) such as vesnarinone, pentoxifylline, milrinone, thalidomide, and thalidomide analogs
(CelSids) decrease the level of inflammatory mediators through transcriptional blockade of

inflammatory gene expression. Agents such as dexamethasone and prednisone and some p38
inhibitors suppress inflammation by blocking the translation of inflammatory mediators (2). Secreted
TNF can be neutralized (3) by soluble TNF antagonists (etanercept) or by neutralizing antibodies
(infliximab) that prevent TNF from binding to its cognate type 1 (p55) and type 2 (p75) TNF
receptors. In addition to these targeted approaches, broad-based immunomodulatory strategies have
been employed (4) using intravenous immunoglobulin (IVIG), statins, and irradiated (oxidized) whole
blood (Celacade therapy). (Modified from Mann DL: Inflammatory mediators and the failing heart:
Past, present, and the foreseeable future. Circ Res 91:988-998, 2002.)

Statins have a variety of pleiotropic effects, including inhibition of inflammatory responses,


increased nitric oxide bioavailability, improved endothelial function, and antioxidant
properties. In addition to inhibiting cholesterol synthesis, statins also lower intermediate
products in the mevalonate pathway including isoprenoids such as farnesyl pyrophosphate
(farnesyl-PP) and geranylgeranyl pyrophosphate (geranylgeranyl-PP), which have been
linked to activation of downstream signaling pathways mediated by Ras and Rho,
respectively ( Fig. 29-10 ). The Ras family of proteins are responsible for cell proliferation
and hypertrophy, whereas the Rho family of proteins are important for superoxide
generation, inflammation, and cytoskeletal formation. Rho inhibition has also been linked to
increased expression of endothelial nitric oxide synthesis, which has a beneficial effect on
endothelial function through increased nitric oxide production. Although the mechanism is
less clear, statins also activate the phosphatidylinositol 3-kinase/Akt pathway, which is
coupled to cytoprotective signaling pathways.[84] In experimental models statins attenuated
LV remodeling and improved LV ejection performance without directly affecting infarct
size. The attenuation in LV remodeling was attributed to decreased cardiac myocyte
hypertrophy, decreased activation of matrix metalloproteinases, and decreased fibrosis.[84]
Importantly, statins have also been shown to promote angiogenesis, mobilize bone-marrow
endothelial progenitor cells, and lead to downregulation of angiotensin type 1 receptorany
or all of which may have an additional beneficial effect(s) on cardiac remodeling.[84] Several
retrospective analyses of clinical trial data bases have suggested that the use of statins has
either reduced the incidence of HF, or reduced mortality in HF patients with known
coronary artery disease.[84] Given the known salutary effects of statins on outcomes in
coronary artery disease, as well as the high prevalence of ischemic heart disease in HF
trials, these findings are perhaps not that surprising. However, several retrospective and
prospective trials have shown that HMG-CoA reductase inhibitors may also be beneficial in
patients with dilated cardiomyopathy ( Fig. 29-11 ). [84] [85]

FIGURE 29-10 The mevalonate pathway leads to the synthesis of cholesterol. Important intermediate
products in the mevalonate pathway include isoprenoids such as farnesyl pyrophosphate (farnesyl-PP)
and geranylgeranyl pyrophosphate (geranylgeranyl-PP), which have been linked to activation Rasand Rho-mediated signaling. 3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase
inhibitors decrease the synthesis of isoprenoids as well as cholesterol, by blocking HMG-CoA
reductase. PP = pyrophosphate. (From Ramasubbu K, Mann DL: The emerging role of statins in the
treatment of heart failure. J Am Coll Cardiol 47:342-344, 2006.)

FIGURE 29-11 Age- and sex-adjusted rates of death from any cause and hospitalization for heart
failure by incident statin exposure. (From Go AS, Lee WY, Yang J: Statin therapy and risks for death
and hospitalization in chronic heart failure. JAMA 296:2105-2111, 2006.)

There have been five prospective trials that have examined the effects of statins in HF
patients. Node and coworkers demonstrated that patients with symptomatic nonischemic
dilated cardiomyopathy (NYHA class II-III) who were randomized to simvastatin for 14

weeks had an improvement in NYHA functional class, improved LV function, and


significant decreases in circulating levels of plasma TNF, interleukin-6 (IL-6), and brain
natriuretic peptide.[86] In a smaller study, Laufs and colleagues randomized a small
number of patients with nonischemic dilated cardiomyopathy (NYHA II-III) to
cerivastatin (0.4 mg) or placebo for an average treatment period of 20 weeks. They
observed that statin treatment resulted in an improvement in the quality of life and
exercise capacity, as well as decreased plasma concentrations of troponin T, hsCRP,
plasminogen activator inhibitor-1, and TNF. In a large (446 patients) prospective
nonrandomized trial, statin therapy was associated with a significant decrease in all-cause
mortality at 2 years (15 versus 33 percent), as well as a significant decrease in HF
hospitalizations (22 versus 38 percent) and nonfatal myocardial infarction (11 versus 15
percent). In this study, statin therapy was associated with a decrease in serum levels of Creactive protein, IL-6, and the type 2 tumor necrosis factor receptor.[87] Two recent
prospective double-blind randomized trials suggested that treatment with atorvastatin (20
to 40 mg/day) is beneficial in patients with nonischemic dilated cardiomyopathy. [87] [88]
Sola and colleagues studied the effects of 20 mg/day atorvastatin in patients with NYHA
class II-IV HF (nonischemic). After 12 months of therapy, there was a significant increase
in LVEF (4 percent) in the atorvastatin group, whereas patients in the placebo group
experienced a decline in LVEF during the same period of time (2 percent). In addition
the LV end-diastolic dimensions decreased significantly in the cohort of patients treated
with atorvastatin, whereas LV end-diastolic dimension increased in the placebo group.
The authors further noted that there was an increase in erythrocyte superoxide dismutase
activity and significant reductions in serum levels of high sensitivity C-reactive protein
(hsCRP), IL-6, and the type 2 tumor necrosis factor receptor in the atorvastatin group,
consistent with a decrease in oxidative stress and inflammation.[90] Similar findings were
reported in a small prospective study that examined the effects of 40 mg/day of
atorvastatin, wherein statin therapy led to a significant increase in LVEF and a significant
decrease in NYHA functional class.[88] However, conflicting results were reported in the
UNIVERSE (Rosuvastatin Impact on Ventricular Remodeling Cytokines and
Neurohormones) trial.[90] This study examined the effect of rosuvastatin (40 mg/day) on
LV remodeling in patients with ischemic and dilated cardiomypathy. Compared to
placebo, rosuvastatin was associated with significant reduction of low-density lipoprotein
cholesterol, but had no effects on LV dimension, LVEF, or neurohormones. Although the
reasons for the discrepant results of the UNIVERSE study are not known, the dose of
rosuvastatin used was comparably higher than that used in previous studies with
simvastatin and atorvastatin.
There are several theoretical concerns with the use of statins in HF. One is that low
circulating levels of cholesterol have been associated with worse outcomes in patients
with HF.[91] It has been suggested that circulating lipoproteins bind bacterial endotoxins
that have been absorbed from the edematous gut of HF patients (the endotoxin-lipoprotein
hypothesis),[92] thereby preventing endotoxin-induced inflammation from occurring.
Theoretically, the lipid lowering effect of statins might be deleterious by allowing
unbound endotoxin to activate immune cells to produce proinflammatory cytokines. A
second theoretical concern is that statins inhibit ubiquinone (CoQ10) synthesis, which
might precipitate or aggravate HF by creating problems with mitochondrial respiration

(see Chap. 22) .

Thalidomide, known for its sedative and antiemetic properties, has been shown to have
broad immunomodulatory properties, and is currently used to treat diseases such as multiple
myeloma, erythema nodosum leprosum, and rheumatoid arthritis. Three small clinical
studies have shown that thalidomide may be beneficial in HF patients. [93] [94] The largest of
the three studies was a double-blind placebo-controlled study, which showed that treatment
with thalidomide (25 mg once dailyincreasing to 200 mg once daily) resulted in
significant increase in LVEF (7 percent) along with a significant decrease in LV enddiastolic volumes. Although the results of these small studies appear promising, doselimiting toxicity has been observed in some HF patients.[93] Accordingly, it will be important
to determine the safety and efficacy of thalidomide in larger clinical trials before this
therapy can be broadly recommended.
In addition to statin therapy several other immunomodulatory approaches appear to be
promising, albeit in selected HF patients. Previous studies have shown that cardiac
autoantibodies directed against cardiac cell proteins such as mitochondrial and contractile
proteins, cardiac beta1-adrenergic receptors, and muscarinergic receptors may play a
pathogenesis of dilated cardiomyopathy. In small nonrandomized noncontrolled studies,
immunoadsorption has been shown to improve cardiac function and patient outcomes.[95]
However, interpretation of these studies is complicated because patients have also received
concomitant therapy with intravenous immunoglobulin (IVIG), which also has
immunomodulatory properties. Therapy with IVIG has been evaluated in a wide range of
immune-mediated disorders, such as Kawasaki syndrome, idiopathic thrombocytopenic
purpura, and multiple sclerosis. Although IVIG had no effect on LVEF in the IMAC trial
(Intervention in Myocarditis and Acute Cardiomyopathy), 6 months of treatment with IVIG
led to a significant increase in LVEF (5 percent), independent of HF etiology, in a doubleblind placebo-controlled study of NYHA functional Class II to IV HF patients.[81] Although
IVIG was safe and well tolerated, the cost of this therapy may limit broader applicability in
HF patients.

Future Perspectives in Immunomodulation


Early attempts to target inflammation using specific anticytokine therapies and broad-based
immunomodulating ap-proaches have been disappointing when examined in phase III
clinical trials. One potential reason for these early failures may be that all currently
approved pharamacological therapies for HF have some antiinflammatory effects.[80]
Accordingly, in future studies it may be necessary to use biomarkers or a pharmacogenetic
approach to select HF patients who have evidence of ongoing inflammation despite optimal
medical therapy. Of the current emerging immunomodulatory strategies, statins appear to be
the most promisingbased on large retrospective and small prospective studies, as well as
their well-established safety profile. This statement notwithstanding, it is important to
emphasize that our current randomized clinical experience with statins in nonischemic
cardiomopathy is limited to several small trials in which fewer than 250 patients have
actually been treated. We have no information with respect to the correct dose of statins to

use in these HF patients. Accordingly, it is premature to recommend the routine use of


statins for all HF patients. There are several ongoing large-scale clinical outcome trials in
HF patients, including CORONA (Controlled Rosuvastatin Multinational Trial in Heart
Failure) and GISSI-HF (Gruppo Italiano per lo studio della sopravvivenza nell'insufficienza
cardiaca [Italian group for the study of the survival in cardiac insufficiency]), which should
provide a more definitive answer(s) to the role of statins in HF.
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