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Exercise training reverses cardiac aging phenotypes associated with heart failure with preserved ejection fraction in male mice


Abstract and Figures

Heart failure with preserved ejection fraction (HFpEF) is the most common type of HF in older adults. Although no pharmacological therapy has yet improved survival in HFpEF, exercise training (ExT) has emerged as the most effective intervention to improving functional outcomes in this age‐related disease. The molecular mechanisms by which ExT induces its beneficial effects in HFpEF, however, remain largely unknown. Given the strong association between aging and HFpEF, we hypothesized that ExT might reverse cardiac aging phenotypes that contribute to HFpEF pathophysiology and additionally provide a platform for novel mechanistic and therapeutic discovery. Here, we show that aged (24–30 months) C57BL/6 male mice recapitulate many of the hallmark features of HFpEF, including preserved left ventricular ejection fraction, subclinical systolic dysfunction, diastolic dysfunction, impaired cardiac reserves, exercise intolerance, and pathologic cardiac hypertrophy. Similar to older humans, ExT in old mice improved exercise capacity, diastolic function, and contractile reserves, while reducing pulmonary congestion. Interestingly, RNAseq of explanted hearts showed that ExT did not significantly modulate biological pathways targeted by conventional HF medications. However, it reversed multiple age‐related pathways, including the global downregulation of cell cycle pathways seen in aged hearts, which was associated with increased capillary density, but no effects on cardiac mass or fibrosis. Taken together, these data demonstrate that the aged C57BL/6 male mouse is a valuable model for studying the role of aging biology in HFpEF pathophysiology, and provide a molecular framework for how ExT potentially reverses cardiac aging phenotypes in HFpEF.
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Aging Cell. 2020;19:e13159. 
 1 of 12
DOI: 10.1111/acel.13159
Exercise training reverses cardiac aging phenotypes associated
with heart failure with preserved ejection fraction in male mice
Jason D. Roh1| Nicholas Houstis1| Andy Yu1| Bliss Chang1| Ashish Yeri1|
Haobo Li1| Ryan Hobson1| Carolin Lerchenmüller2| Ana Vujic3|
Vinita Chaudhari1| Federico Damilano1| Colin Platt1| Daniel Zlotoff1|
Richard T. Lee3| Ravi Shah1| Michael Jerosch-Herold4| Anthony Rosenzweig1
Thisisanop enaccessarti cleundertheter msoftheCreativeCommonsAttributionL icense,whichpe rmitsuse,dis tribu tionandreprod uctioninanymed ium,
provide d the original wor k is properly cited.
©2020TheAuthors.Aging Cellpublis hedbyAnatomicalSocietyandJohnWiley&SonsLtd
1CorriganMinehanHear tCenter,
Massachuset tsGen eralHospita l,Har vard
MedicalSchoo l,Boston,MA ,USA
2Depar tmentofCardiology,Angiolog y,
andPulmonolog y,UniversityHo spital
3Depar tmentofStemCellandRegenerative
Biolog y,Harva rdStemCellInstitute,
HarvardUnive rsity,Cambridge,MA ,USA
4Depar tmentofRadiol ogy,Brighamand
Women’sHospital,HarvardMedic alScho ol,
Boston ,MA,USA
JasonD.Roh ,Massachuset tsGe neral
Hospit al,SimchesResearchCe nter,Room
3.186,Bos ton,MA02114,USA.
Funding information
AmericanHeartAssociation,Gr ant/
AwardNumber:16F TF29630016and
16SFRN3172000;NationalI nstituteon
Aging ,Grant /AwardNumb er:AG0 47131,
Heart,Lung ,andBlo odInst itute,G rant/
AwardNumber:HL119230 ,HL122987
StiftungFound ation;Deutsc he
Number :DGFLE32571-1;FredandInes
YeattsFundf orInnovativeResearch
Heart failurewithpreservedejectionfraction(HFpEF)isthe mostcommontypeof
HFin olderadults. Althoughnopharmacological therapyhasyetimprovedsurvival
improving fu nctional outcomes in t his age-related disease. T he molecular mecha-
nismsbywhichExTinduces itsbeneficialeffectsin HFpEF,however,remainlargely
that ExTmight reverse cardiac agingphenotypes that contribute to HFpEF patho-
physiology and additionally provide a platform for novel mechanistic and therapeutic
reserves,whilereducingpulmonarycongestion.Interestingly,RNAseqof explanted
heartsshowedthatExTdid notsignificantlymodulatebiologicalpathwaystargeted
was associated with increasedcapillary density, but no effects on cardiac mass or
andprovide a molecular framework forhowExTpotentially reverses cardiac aging
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heterogenous clinical syndrome strongly associated with advanced
age (Upadhya, Taffet,Cheng, & Kit zman, 2015). It nowrepresents
themost commonform of HF in olderadults withagrowing prev-
alence largelyattributed to globalpopulation aging (Dunlay,Roger,
& Redfiel d, 2017). Unfortunately, prognosis for older adults wit h
hospit alized for HF are eith er readmitte d or dead within 9 0 days
of discharge (Upadhya et al., 2015). Not ably, no pharmacological
agent, includingneurohormonalant agonistsandnitrate derivatives
(Borlauget al.,2018;Massieetal.,2008;Pitt etal., 2014;Redfield
etal., 2015), hasimproved survival in HFpEF,making itone of the
largest unmet needs in geriatric and cardiovascular medicine (Parikh
The reasons we lack effective pharmacologic al inter ventions
in HFpEF are multifold, but largely stem from an incomplete
unders tanding of the u nderlying me chanisms that dr ive HFpEF
pathophysiology (Roh, Houstis, & Rosenzweig, 2017). In older
adults, molecular,struc tural,an dfunc tionalchanges associated
tributorstoHFpEF(Roh, Rhee,Chaudhari, &Rosenzweig, 2016;
Strait&Lakatt a,2013;Upadhyaetal.,2015). However,whether
the biology of cardiac agingcan be targeted forHFpEF therapy
is unclear.
Despite limitedsuccess of currentpharmacologicalagents,aer-
obic exercisetraining(ExT) has emerged as one of themost effec-
tive strategies for improving functional outcomes in older adults
with HFpEF (Edelmann etal., 2011; Kit zman et al., 2016; Kit zman,
Brubaker,Morgan, Stewart,&Little, 2010; O’Connor etal., 2009).
Whether ExT can alter cardiac aging phenot ypes that contribute
to HFpEF patho physiology, however, is contr oversial. Whil e some
studies have suggested that ExT improves diastolic func tion and
cardiac r eserves i n older HFpEF pati ents, othe rs have shown that
ExThasminimalef fect sonthesecardiacagingphenotypes(Angadi
etal.,2010,2016 ;N ol teetal.,2014).Mo re ov er,themo le cul ar mech-
anisms by whi ch ExTp otentially imp roves cardiac pe rformance i n
This study addresses these critical issues by first demonstrat-
associatedwith HFpEF.Finally, combining RNAseq profiling and
ExT in an integrate d platform for therapeut ic target discover y
provides a scientific rationale for why previous drug targets may
havefailedinclinical HFpEF trials and implicatesalternative bi-
ological pathways as candidates for therapeutic inter vention in
2.1 | Cardiac functional HFpEF phenotyping
Since advanced age represent s one of the dominant risk factors
for HFpEF, we hypothesized that old mice might share hallmark
phenot ypes prese nt in human HFpEF. Toev aluate the aged m ouse
as a HFpEF model, we firstset criteria based on the most common
pathophysiologic features seen in clinical HFpEF (Borlaug, 2014;
left ventricular(LV)systolic function,measured by ejec tion fraction
(EF) or fr actional sh ortening (FS ); (b) impaired exer cise capacit y; (c)
impairedcontractile orchronotropicreserves; (d)increasedintracar-
diac filling pressures, B-type natriuretic peptide (BNP) expression,
orpulmonary congestion;and (e)histologicfeaturesconsistentwith
performed comprehensivephenoty pingin young (3–4months), old
(24–26mo nths), and very ol d (28–30 months) C57BL/6 male m ice.
phenot ypes progressed in the late stages of th e murine lifespan to fur-
tensive multimodality approach. Transthoracic echocardiography per-
formed in a large cohort of animals (n=43)foundthatLVfractional
shor ten in gw asge ner al lypre ser ve dinoldand ve r yo ld mi ce ,c ompar ed
toyoung mice(Figure1a).Importantly,this definingfeatureof HFpEF
was further validated in smaller subgroups using cardiac magnetic res-
onance imaging (Figure S1) and invasive intracardiac hemodynamic
tes ting(Fig ureS2).SimilartohumanHFpEF,botholda ndver yoldmice
displayed evidence of subclinicalLVsystolic dysfunctionas reflected
2.2 | Exercise HFpEF phenotyping
The most c onsistent fun ctional im pairment se en in clinical H FpEF
is exercise intolerance (Borlaug, 2014). Using stress echocardi-
ography, we found that exercise capacity was markedly reduced
in old and ver y old mice, even when adjusted for body weight
etal.,2019;Fleg et al., 20 05;Strait & Lakatta,2013), therewasan
age-associateddecline in exercisecapacity that fur ther progressed
from 24 to 30 months (Figure 2a). Bothchronotropic andcontrac-
reser ves continued to de cline from 24 to 30 months (F igure 2b).
capacity(Figure2c), suggestingthattheimpairments in cardiac re-
servesseen in oldermice likelycontributetotheir age-relatedde-
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2.3 | Histopathologic cardiac HFpEF phenotyping
heartsfrom HFpEFpatientshasrevealedacommonpathologiccar-
diac hypertrophy phenotype that includes increased cardiomyocyte
Todetermine whether aged C57BL/6 male mice exhibit these his-
topathologic HFpEF phenotypes, we first performed gravimetric
analyseson young,old,andvery old mice. Indexedlungweights,an
indicator of pulmonary congestion, increased with age (Figure S4),
sugges ting that as the se mice age, a progr essive HF syn drome oc-
curs that parallels the age-related decline in functional exercise ca-
seenbetween4and26months,therewasnofur ther increaseaf ter
young and old age groups. Old mice fully recapitulated the patho-
logic cardiac hypertrophy seen in human HFpEF,demonstrating in-
creased cardiomyocyte size, myocardial fibrosis, and microvascular
rarefaction(Figure 3a),whichwasassociatedwithincreasedcardiac
BNPexpression,abiomarker ofincreasedmyocardialstress and HF
(Figure 3b). N otably, blood pres sures were similar b etween young
and old mice (Figure 3c), suggesting that the pathologic cardiac re-
modeling seen in aged mice is not driven by overt hypertension but
more likely related to processes intrinsic to cardiovascular aging.
2.4 | Reversal of HFpEF phenotypes in aged
C57BL/6 male mice with exercise training
Since aged C 57BL/6 male mice recap itulate many of the H FpEF
FIGURE 1 Age-relatedchangesinrestingcardiacfunctioninC57BL/6malemicearesimilartocardiacfunctionalphenotypesinhuman
HFpEF.NonsedatedtransthoracicechocardiographyinC57BL/6malemiceat3–4months(young( Y),n=12),24–26months(old(O),n=17),
mean ± SEM,withallindividualdatapointsplotted.One-wayANOVAwithposthocTukey'stestusedforanalyses.*p<.05,**p<.01,***p < .001
FIGURE 2 Progressiveage-relateddeclineinexercisecapacit yandcardiacreservesinC57BL/6malemicerecapitulatesexercise
intolerancephenotypesinhumanHFpEF.StressechocardiographytestinginC57BL /6malemiceat3–4months(Y,n=12),24–26months
bodyweight).(b)Chronotropicandcontractilereservesmeasuredatpeakexercise.(c)Pearsoncorrelationofexercisecapacit y(work)with
ANOVAwithposthocTukey'stestusedforanalyses.*p<.05,**p<.01,***p < .001
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ExT could effectively reverse these age-related HFpEF phe-
notyp es. Mice were match ed based on body w eight and HFpEF
phenotypes (Table 1) and then divided into either an 8-week
modera te-intensity trea dmill running prot ocol (45 min at 10 m/
minat10° incline)versus no intervention(normalsedentary life-
style)(Figure 4a). ExTinducedmultiplefunctional improvements,
et a l.,2 015 ; Ede l m a nne t al., 2 011;H a y ko w s k yet a l .,2 0 12; K i t z man
etal., 2010, 2016; Nolteet al., 2014). Specifically,improvements
inexercise capacity,systolic strain, diastolic function,contractile
reserves, and pulmonary congestion were seenaf tereight weeks
ofExT(Figure 4b–e, FigureS5).Although cardiacmass and fibro-
2.5 | Exercise-mediated transcriptome changes
in the aged heart
Toexplorethe molecular pathwaysthroughwhich ExTmodulatescar-
diacaging phenotypesassociatedwithHFpEF,we per formedRNAseq
ona subsetof cardiacsamples fromtheExTandsedentary aged mice.
Fourteengenes (11of whichareknown) were differentially expressed
after adjusting for multiple hypothesis testing (Figure 5b, Table S1).
Although RNAseq revealed only a small number of genes in the aged
heart that were differentially regulated by ExT, gene setenrichment
analysis did identify 479 significantly upregulated and 77 downregu-
lated biological pa thways (Tables S2 and S3). Inte restingly, pathways
associated with drug targets previously tested in clinical HFpEF trials,
that is, adrenergic, renin–angiotensin–aldosterone (RAAS) and nitric
oxide-cGMP-phosphodiesterase signaling pathways, were generally
not significantly altered by ExT, although positive regulation of nitric
oxide synt hase biosynthe sis reached our sign ificance thres hold (NES
trend(NES1.64,FDR 0.26)(Table2).Ratherthepathwaysmosthighly
upregulated by ExTwere predominantly cell cycle-related processes,
while the most highly downregulated were related to cellular respiration
(TablesS2and S3). Takentogether,thesedatasuggest that the cardiac
bedriven more bychangesin thesealternativebiologicalpathways, as
opposed to the neurohormonal pathways that are targeted with current
FIGURE 3 Pathologic cardiac
recapitulates histopathologic cardiac
cardiacmRNAexpressionofBNP.n = 5/
group.(c)Systemicmeanar terialpressure
with all individual data points plot ted.
UnpairedStudent'st test used for
analyses.*p<.05,**p<.01,***p < .0 01
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2.6 | Reversal of cardiac aging pathways by
exercise training
scriptome changes with normal aging to provide a comparison to the
RN A seq ana lys e si d ent ifi eda lar gen umb ero fg ene sth atw ere dif f er-
(Figure 5a,TableS4).Gene set enrichmentanalysisconfirmedthat
biological processes implicated in cardiac aging were changing in the
expec ted directi ons in our aged mice (B ergmann et al ., 2009; Dai
Brand,Weindruch,&Prolla,2002; Roh etal., 2016). Inflammation,
cytokineproduction,complement activation,andextracellularma-
trixproductionpathwayswereupregulatedintheagedhear t,while
cellcycle, DNA repair,mitochondrial function, oxidativephospho-
rylation,fatt yacidmetabolism,cardiaccontractilityand relaxation,
regulate d (Tables S5 and S6). Notab ly,t he generalized i ncrease in
chronic inflammatory processes of the innate immune system along
with downregulation of pathways relevant to cardiac muscle me-
chanics and vascular growth highlights the parallels between cardiac
agingbiology andleadingHFpEFhypotheses,whichhaveproposed
a central role for microvascular inflammation inducing the cardio-
ExT(30 mo sedentary vs. 30moExT)cohorts identified 216 path-
(TablesS2,S3,S5 and S6).Ofthese 216pathways, the most highly
significant changes predominantly occurred in cell cycle or cell di-
vision pathways (Figure5c), suggesting thatreversingimpairments
in this hallmark of aging (Lopez-Otin, Blasco, Partridge, Serrano,
& Kroeme r,2013) may b e an import ant contribut or by which ExT
improves the performance of the aged heart. The main drivers of
cycle, mitoticcellcycle)wereHAUS8, GADD45A, MAPRES2, MCM5,
and FANCI. In creased exp ression tre nds of these gen es were vali-
dated by QPCR in an independent cohort of old male mice that
underwent eight weeks of voluntary wheel running (Figure S6a),
sug gestingthatdifferentmo de sofaerob icExTcaninducesim ilarbi-
robustasthecellcyclechangesnoted above,ExTalsoreversedthe
downregulation of ubiquitin–proteasome,cellular st ressre sponse,
heatshockproteinbinding,andfat tyacidmetabolismpathwaysas-
sociatedwithaging( TablesS2,S3,S5andS6).
HFp EF is ac li ni c al sy ndr om ew ithhigh mo rbidi tyand mo r talit y,mo st
commonlyseenin olderadults (Dunlayet al., 2017). Given the lack
of effec tive pharm acologic al therapi es for this dis ease, along w ith
its projected future growth with ongoingpopulation aging, HFpEF
has been labeled as one of the largest unmet needs in cardiovascular
medicine(Parikh et al.,2018). The reason for the lack of effective
therapiesinHFpEFismultifold ,butlargelyduetoanincompleteun-
derstandingofitscomplexpathophysiolog y.
which is the limited number of animal models to identify and study
causal molecular mechanisms in HFpEF (Roh et al., 2017). Previous
studieshave suggested that although aged mice exhibit some fea-
(Daiet al.,2009;Eisenberget al., 2016).Themerepresenceofcar-
diacHFpEFphenotypes inmicedoesnotnecessarily equateto the
clinicalsyndromeofHF,whichisinherentlydifficult toascertainin
animals . However, our comprehe nsive funct ional, histol ogical, an d
molecular phenot yping provides strong evidence that the aged
C57BL/6 male mo use capture s many of the major c ardiac pheno -
types that have been implicated as core pathophysiologic mediators
ofHFpEF(Borlaug,2014).Importantly, the HFpEF phenotypes ob-
serve d in aged C57BL/6 male mic e occur in the abse nce of overt
hypertension, which has been a common adjunct intervention
used to generateHFpEF phenotypes in animal models(Eisenberg
etal.,2016;Hulsmans et al., 2018; Schiattarellaetal., 2019).Thus,
TABLE 1 Baselinecharacteristicsof28-month-oldC57BL/6
(n = 7)
(n = 7)
Age(month) 28 28 n.a.
Sex male male n.a.
Strain C 57 BL /6 C57B L/6 n.a.
Weight(g) 31.6±2.9 34.8 ± 3.5 .09
Resting cardiac function
52.9 ± 3.2 50.2 ± 2. 8 .12
Distance(m) 131.5±26.3 136.2±19.4 .71
Work(Joules) 7.0±1.5 8.0±0.7 .16
Lact ateatpeak
8.2±1.6 9.0 ± 1.1 .28
Cardiac reserves
665.5±17.5 664.3±46.8 .95
0.2 ± 8.4 2.2 ± 5.0 .59
Note: Priortoinitiationoftheexercisetrainingprotocol,nosignificant
baselinedifferencesinbodyweight,res tingcardiacfunction,exercise
capacity,orcardiacreservesweredetec tedbet weenthesedentary
UnpairedStudent'st test used for analyses. p < .05 considered
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a valuabl e and comple mentar y model of HFpEF bu t is partic ularly
well suitedfor studying the role ofaging biology inHFpEF patho-
physiolog y.This supportsanemergingparadigm inthisfield, which
tic discover y and implementation will likely need to focus on specific
The second major aim of this study was to begin to elucidate
phenotypes thatcontributetoHFpEF inolderadults.AerobicExT
and caloric restriction have been the only interventions to improve
functionalcapacity inolder HFpEFpatient sinrandomizedclinical
diac tissue, the molecular mechanisms by which these interven-
wefocused specifically on ExTwith the hypothesisthat it would
inducesimilarfunctionalben efitsint heagedC57BL/6malemouse
and that RN Aseq analy ses of cardiac ti ssue would not onl y pro-
videmechanisticinsightsintotheroleof ExTin cardiacaging,but
somecardiacHFpEFphenotypesinthis model,itimproves overall
cardiac p erform ance and exerc ise capacit y.We pr opose that t he
functional parallels seenwithExTin thesemiceand humanswith
HFpEF not only p rovide fur ther suppor t for the use of t he aged
C57BL/6 male mo use as a model of age- related HFpEF, but also
for the use of ExT as a platform for therapeuticdiscover y in this
thetra ns cr ipto meofth ea ge dh ea rtinthecontex toffunct ionalphe-
notyping. Our analyses provide two major mechanistic insight s into
thetherapeutic roleof ExTinage-related HFpEF.First, in the aged
male hear t, ExTdoes not significantly regulatebiologicalpathways
associated with conventional HF drugs, including β-blockers and
orcellularresponses to NO was detectedin our pathway analysis,
whichcould suggestthatNObiologymaystillbea promisingther-
apeuti c target for age-re lated HFpEF. However, given the neutr al
result s in randomi zed controlle d trials wit h organic nit rate and in-
organic nitritetherapies(Borlaugetal., 2018;Redfield etal.,2015),
alternat ive approac hes to target ing this biolo gy need to ex plored.
Second,incontrast to its lack of effect on thetranscriptionalpro-
file of neurohormonal pathways, ExT induced a marked reversal in
aged hear t (Figure 5c). T his study was no t designed to det ermine
in capill ary densit y and upregu lation of angioge nesis pathways , in
the absen ce of cardiac mas s or fibrosis cha nges, sugges t that en-
dothelialproliferation is likelyinvolved, whichwould be consistent
FIGURE 4 AerobicexercisetrainingreversessomeHFpEFphenot ypesinagedmalemice.(a)Experimentaldesignofexercisetraining
normalizedtotibiallength( TL).(f)Heartweight(HW)normalizedtoTL.(g)%Fibrosis.(h)Capillar ydensity.Forfibrosisandcapillarydensity
the final analyses. Data shown as mean ± SEM,withallindividualdatapointsplotted.UnpairedStudent'sttestusedforanalyses.*p<.05,
**p<.01,***p < .001
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be contributing to this signal. Recent work from our group has shown
often promote otherpro-survivaland protective growth pathways
incardiomyocy tes(Bostrometal.,2010;Liuetal.,2015).Giventhe
profound cardiomyocyte loss and reduced regenerative capacity
in the aged h eart (Ber gmann et al., 2 009), even smal l increases i n
cardiomyogenesis would likely have substantial impacts on cardiac
Atanindividualgene level,after adjusting formultiple hypoth-
esis test ing, our RNAs eq analyses di d identify 11 cand idates that
were dif ferentially reg ulated by ExT in the aged he art (Figure 5a ,
TableS1).Ofthese11candidates,theincreasesinSORL1 and AC TA 1
expression were fully validated by QPCR in an independent ExT
cohortof old mice(FigureS6b).SORL1encodesforthesortilin-like
receptor 1, a low-density lipid receptor, whose downregulation
has been implicated in age-related Alzheimer disease (Rogaeva
etal., 20 07). Although SORL1 hasyetto be studied in the context
recycli ng, it is possib le that its u pregulati on by ExTc ould mitiga te
ExT-inducedupregulationofcardiacAC TA1 expressioninagedmice
wasunexpected.ACTA 1 is a member of the “fetal" gene profile typ-
ically increased in pathological cardiac hypertrophy and downregu-
Kelly,&Leinwand,2017). However,high-intensityExTcan increase
AC TA1 expre ssion in the he art (Cast ro et al., 2013). It is pla usible
thateventhoughourExTprotocolwas initiallygradedasmoderate
differenceinc ardiac massin our ExToldmice,average cardiomyo-
cyte size i ncreased by ~1.4-fold, whic h would be consistent w ith
the increased cardiac AC TA1 expressionobservedwithExT.Further
ential effects on the “fetal gene” profile associated with pathologic
FIGURE 5 Reversalofcardiacagingpathwayswithexercisetraining.RNAseqanalysesoncardiactissuefromyoung(4months)
sedentary,veryold(30months)sedent ary,andveryold(30months)exercise-trained(ExT)C57BL/6malemice.ExTmicecompletedan
8-weektreadmillrunningprotocolfrom28to3 0monthspriortosacrifice.n=3/group.(a)Volcanoplotofdifferentiallyexpressedgenes
andExT(blue,veryoldsedentaryvs.veryoldE xT).OnlypathwayswithanFDR<0.05inboththeagingandexercise-trainedcohor tswith
red = padj < .05; green = log2(FC)≥1+padj < .05
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ofwhetherthefetal geneexpressionprofilecanreliablydistinguish
between physiologic and pathologic hypertrophy in older animals
and humans. Evidence in humans has suggested that moderate in-
tensity distance running specifically increases circulating BNP,an-
other member of the pathologic cardiac hypertrophy fetal gene
profile,in older,butnot youngerhumans (Kim et al., 2017). In our
fibrotic changes suggest that despite an overall upregulation in the
fetal gene expression profile, exercise appears to induce a benefi-
cial effect in the aged murine heart. Lastly,it is important to note
changes in targets thathavebeen previously reportedinExTaged
rodents,suchasSERCA2a,VEGF,andSIRT1(Laietal.,2014;Lemit su
TABLE 2 EffectsofexercisetraininginagedheartsonbiologicalpathwaysassociatedwithpreviouslytesteddrugtargetsinHFpEF
Pathway NES FDR
Adrenergic system
Adrenergicreceptoractivity 0.89 0.81
Adrenergicreceptorbinding 0.69 0.94
Adrenergicreceptorsignalingpathway 0.88 0.82
Catecholamine binding 1.01 0.73
Catecholamine biosynthetic process 0.95 0.76
Catecholamine metabolic process 1.33 0.49
Catecholamine transport 1.18 0.60
Negativeregulationofcatecholaminesecretion 1.01 0.73
Positive regulation of catecholamine metabolic process −1. 13 0.82
Regulation of norepinephrine secretion −1. 0 0 0.88
Response to epinephrine −1. 3 8 0.71
Renin–angiotensin–aldosterone system
Angiotensinreceptorbinding −0.85 0.93
Regulationofbloodvolumebyrenin–angiotensin 0.98 0.75
Regulationofsystemicarterialbloodpressurebycirculatingrenin–angiotensin 1.48 0.38
Regulationofsystemicarterialbloodpressurebyrenin–angiotensin 1.45 0.40
Response to mineralocorticoid −0.86 0.93
Nitric oxide-cGMP-phosphodiesterase system
3’5’cGMPphosphodiesteraseactivity −1.56 0.57
Cellularresponsetonitricoxide 1.64 0.26
cGMP binding −1. 13 0.82
cGMP biosynthetic process 1.10 0.66
cGMP met abolic process 1.08 0.68
Negativeregulationofnitricoxidemetabolicprocess 0.95 0 .76
Nitricoxidemediatedsignaltransduction −1.4 5 0. 67
Nitricoxidemetabolicprocess 1. 29 0.52
Nitricoxidesynthasebinding −1.08 0.84
Positiveregulationofnitricoxidesynthaseactivity 0.96 0.90
Positiveregulationofnitricoxidesynthasebiosyntheticprocess 1.67 0. 24
Regulation of cGMP biosynthetic process −1. 0 3 0.86
Regulation of cGMP metabolic process 1.08 0.68
Regulationofnitricoxidebiosyntheticprocess −0.86 0.93
Regulationofnitricoxidesynthaseactivity −0.77 0.97
Regulationofnitricoxidesynthasebiosyntheticprocess 1.42 0.42
Responsetonitricoxide 1.50 0.36
Note: GenesetenrichmentanalysisofRNAseqprofilesfromcardiactissueofsedentaryver susexercise-trainedagedmalemiceusingtheGene
Ontolog y pathway dataset. N=3/group.NES=normalizedenrichmentscore.Falsediscover yrate(FDR )<0.25consideredsignificant.
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Some limitations of the study warrant emphasis. First, this
study wa s done exclusive ly in male mice and , thus, does no t ad-
dresssex-relateddifferences inage-relatedHFpEF.Evidencesug-
gests that there are likely molecular differences in how male and
physiologicandpathologicstress(Konhilaset al., 200 4;Piro,Della
Bona,Abbate,Biasu cci,&Crea,2010;Weinbergetal.,1999).While
our findings strongly suggestthat theaged C57BL /6male mouse
cluded ma ny of the core path ophysiologic f eatures in ou r HFpEF
phenotyping,thisdid not include assessmentofotherpotentially
causal comorbidities, such as obesity, or the role of peripheral
mechanisms in HFpEF pathophysiology (Borlaug, 2014; Kitzman
etal ., 20 16).Nonc a rd iacph enotyp eslikel yc on tri butetot he age-re-
investigated.Third, while nodifferences insystemicarterialpres-
forchangesinaortic stiffness,whichincreases with ageandcould
also be contributing to the pathologic cardiac hypertrophy pheno-
type seen in this aged mouse model (Fleenor et al., 2014). Lastly,
se si na ge dhe arts ,fu tu res tud ie swill ne e dt od ef i ne thesp eci ficce ll
populations driving the functional and molecular changes induced
lational modifications of protein.
Takento gether, this stu dy address es some of the ma jor short-
comings in HFpEF research, particularly in the context of aging.
It esta blishes the age d C57BL/6 male mouse as a v aluable mod el
for stud ying the role of agin g biology in HFpEF pat hophysiology.
Moreover, by using E xTas a pl atform for t herapeu tic discover y,it
sentpromising targets fortherapeuticdevelopmentin age-related
4.1 | Mice
All animal studies were approved by the Beth Israel Deaconess
Medical Center and Massachusetts General Hospital Institutional
Animal CareandUse Committees.Aged C57BL/6males were gen-
erouslyprovidedbytheNationalInstituteonA ging.AgedC57BL/6
females were unavailable atthetime ofthisstudy.YoungC57BL/6
4.2 | Echocardiography
Echocardiography was performed on unanesthetized mice with
Vivid 7andE90systems (GEHealthcare). Systolicfunctionwas as-
sessed byfractional shortening and radial systolic strain, while di-
astolic function was assessed by early diastolic strain rate. Refer to
supplemental methods for details on echocardiographic image ac-
4.3 | Cardiac magnetic resonance imaging
Mice were ane sthetized wit h isoflurane an d imaged using a 9.8-T
MRIsys tem(BrukerBiospi n).Refertosuppl ement almet ho dsf ord e-
tails of the cardiac MRI protocol.
4.4 | Invasive intracardiac hemodynamics
Mice were ane sthetized w ith isoflura ne and mechan ically venti-
latedthroughouttheprocedure.TheLVwasenteredvia theright
carotid arterywithaScisence1.2Fhigh-fidelitymicromanometer
catheter(TransonicSystems Inc.)to record pressure-volume(PV)
loops. PV loopswereanalyzedoff-linewithLabScribe2 software
4.5 | Stress echocardiography exercise testing
Tome asure exercis e capacit y and cardia c reser ves, a stres s echo-
cardiography protocolwasdesignedinwhichmice were run to ex-
haustion and then immediately imaged via echocardiography. Refer
to the supplemental methods for details of the protocol.
4.6 | Exercise training protocols
Twoaerobicexercisetrainingprotocolswere used in this study.In
the initial discovery cohort, moderate-intensity treadmill running
was performed five days per week for eight consecutive weeks.
Treadmill running was done on an automated treadmill (Columbus
Instruments) at a constant speed of 10 m/min at 10° incline. To
ensure that the biologicaleffectsof ExTwerenotlimited to aspe-
cifictypeof aerobicexercise, wealsoperformed eight consecutive
weeks of vol untary wh eel running (S TARR Life Science s)i n an in-
dependent validation cohort, usingpreviously published methods
4.7 | Histologic and immunohistochemical analyses
Formalin-fixed, paraffin-embedded mid-ventricular sections were
stained with periodic acid–Schiff for cardiomyocyte cross-sectional
10 of 12 
     ROH et al .
area (CSA), Masson's trichrome for fibrosis, and rabbit-anti-mouse
CD31(1:50,CellSignalingTechnologies,#77699)forcapillar ydensity.
(40–60 cells/section,~200cells/hear t),which wereaveragedto rep-
resentasingledat apointfore achheart.C apillarydensityw asquanti-
fied by dividing the number of CD31+cellsbythearea of randomly
selected sections. Three to five sections were measured per heart and
ity in fibrosis distribution throughoutthe hear t, BZ-XAnalyzer soft-
ware (Keyence)was used to quantify fibrosis in full mid-ventricular
sections. Percent fibrosis was calculated as the ratio of fibrotic area
to total tissue area. Measurements from two sections were averaged
to represent a single data point for each heart. Quantitative histologic
analyses were done in a blinded fashion.
4.8 | Quantitative real-time PCR
Real-time PCR productswere carried out using SYBR-green and
standard amplification protocols. Expression levels were cal-
culated using the ΔΔCt method. Prim er sequences ar e listed in
4.9 | RNA sequencing
RNA sequencing was performed by the MGH Sequencing Core.
Ultra DirectionalRNALibrary Prep Kit(NewEngland Biolabs)andse-
quenced o n Illumina HiSe q2500 inst rument. Th e R package DES eq2
was used fo r differentia l gene expressio n analysis. Ge nes were con-
sidered differentially expressed if upregulated by log2FC>+1 or
downregulated by log2FC<−1 with an adjusted p value < .05 (using
Ontology database. For all differentially expressed genes, a metric
wascomputedasthe productof logFCand−log10(p-value).A“running
sum” statistic was calculated for each gene set in the pathway dat a-
base based on the ranks of the members of the set relative to those of
sum of the ru nning sum wit h the genes ma king up this ma ximum ES
contributingtothe coreenrichmentinthat pathway.Anormalizeden-
scores for all dataset permutations. Pathways with a false discovery
4.10 | Statistical analyses
RNAseq and GSE A data analyses were performed with R and
sion7.0)was usedforallotherdataanalyses.Inallgraphs,dataare
shown as means ± SEMwithallindividualdatapointsdisplayed.For
comparisons of two groups,unpaired Student's t test s were per-
formed.For comparisons of≥3 groups, one-wayANOVA followed
methodwasusedforcorrelationstudiesinFigure2.p value <.05 was
considered statistically significant.
This work was suppor ted by the NIH (AG0 47131, AG061034,
AG064328, HL119230, HL122987, HL135886), AHA
(16SFRN31720000, 16FTF29630016), German Research
Foundation (DFG, LE 3257 1-1), Else-Kroner-Fresenius-Stif tung
Foundation, and the Fred and Ines Yeatts Fund for Innovative
BC,AYe,HL,RH,VC ,CL,AV,CP,FD,DZ,RS,MJH,andRTLassisted
with tissueanalysesand/ordat ainterpretation.JDR and AR wrote
the manuscript with contributions from all authors.
The data that support the findings of this study are all present
in the paper or the Supplemental Materials. The raw RNA se-
quencingdatausedinthisstudywillbeavailableintheNCBISR A
Jason D. Roh
Haobo Li
Ryan Hobson
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How to cite this article:RohJD,HoustisN,YuA,etal.Exercise
training reverses cardiac aging phenotypes associated with
heart failure with preserved ejection fraction in male mice.
Aging Cell. 2020;19:e13159. htt ps://doi.or g/10.1111/
... [85][86][87] Investigation into exercise-induced epigenetic changes within specific populations, such as individuals with CVD, will enhance our understanding of how exercise promotes beneficial cardiovascular adaptations. 88,89 Furthermore, the identification of motor-regulated molecules as potential biomarkers holds significant importance in guiding safer and more effective exercise training for CVD patients, as well as predicting patient prognosis. Overall, the evidence presented in this review emphasizes the need for a comprehensive understanding of the signaling pathways and mechanisms involved in the cardiovascular health benefits of exercise, which will greatly contribute to the identification and development of innovative treatment targets and strategies to combat CVD in the future. ...
... Several potential mechanisms might underlie the observed relations between a healthy lifestyle and HF. Animal studies have shown that exercise training (ExT) can reverse cardiac aging phenotypes associated with heart failure with preserved ejection fraction (HfpEF) in male mice, and its molecular mechanism involves that ExT reversing the downregulation of fatty acid metabolism pathways related to aging and ultimately regulating the cell cycle and cell division [49]. Other animal studies in mice have also shown that the improvement of heart failure by exercise is related to the recovery of oxidative metabolism [50], the β3-AR-nNOS-NO pathway [51], autonomic imbalance, and impaired calcium homeostasis [52]. ...
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Lifestyle has been linked to the incidence of heart failure, but the underlying biological mechanisms remain unclear. Using the metabolomic, lifestyle, and heart failure data of the UK Biobank, we identified and validated healthy lifestyle-related metabolites in a matched case-control and cohort study, respectively. We then evaluated the association of healthy lifestyle-related metabolites with heart failure (HF) risk and the added predictivity of these healthy lifestyle-associated metabolites for HF. Of 161 metabolites, 8 were identified to be significantly related to healthy lifestyle. Notably, omega-3 fatty acids and docosahexaenoic acid (DHA) positively associated with a healthy lifestyle score (HLS) and exhibited a negative association with heart failure risk. Conversely, creatinine negatively associated with a HLS, but was positively correlated with the risk of HF. Adding these three metabolites to the classical risk factor prediction model, the prediction accuracy of heart failure incidence can be improved as assessed by the C-statistic (increasing from 0.806 [95% CI, 0.796-0.816] to 0.844 [95% CI, 0.834-0.854], p-value < 0.001). A healthy lifestyle is associated with significant metabolic alterations, among which metabolites related to healthy lifestyle may be critical for the relationship between healthy lifestyle and HF. Healthy lifestyle-related metabolites might enhance HF prediction, but additional validation studies are necessary.
... The age-related impairment in cardiomyocyte relaxation and the normalization by rapamycin treatment are consistent with age-related diastolic dysfunction observed in old mice that can be reversed by rapamycin treatment 12,13 . Previous studies have shown that LV systolic function is relatively preserved or slightly reduced with aging at organ levels 13,48,49 . The age-related declines in sarcomere fractional shortening and contraction kinetics suggest that cardiac (which was not certified by peer review) is the author/funder. ...
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Diastolic dysfunction is a key feature of the aging heart. We have shown that late-life treatment with mTOR inhibitor, rapamycin, reverses age-related diastolic dysfunction in mice but the molecular mechanisms of the reversal remain unclear. To dissect the mechanisms by which rapamycin improves diastolic function in old mice, we examined the effects of rapamycin treatment at the levels of single cardiomyocyte, myofibril and multicellular cardiac muscle. Compared to young cardiomyocytes, isolated cardiomyocytes from old control mice exhibited prolonged time to 90% relaxation (RT90) and time to 90% Ca2+ transient decay (DT90), indicating slower relaxation kinetics and calcium reuptake with age. Late-life rapamycin treatment for 10 weeks completely normalized RT90 and partially normalized DT90, suggesting improved Ca2+ handling contributes partially to the rapamycin-induced improved cardiomyocyte relaxation. In addition, rapamycin treatment in old mice enhanced the kinetics of sarcomere shortening and Ca2+ transient increase in old control cardiomyocytes. Myofibrils from old rapamycin-treated mice displayed increased rate of the fast, exponential decay phase of relaxation compared to old controls. The improved myofibrillar kinetics were accompanied by an increase in MyBP-C phosphorylation at S282 following rapamycin treatment. We also showed that late-life rapamycin treatment normalized the age-related increase in passive stiffness of demembranated cardiac trabeculae through a mechanism independent of titin isoform shift. In summary, our results showed that rapamycin treatment normalizes the age-related impairments in cardiomyocyte relaxation, which works conjointly with reduced myocardial stiffness to reverse age-related diastolic dysfunction.
... Physical activity promotes healthy aging and prevents CVD [162][163][164][165] . Progressive and vigorous exercise for 1 year in previously sedentary people aged 65 and over induces physiological LV remodeling, increases stroke volume and total aortic compliance, and decreases arterial elastance [166] , while studies in aged mice correlated the benefits of exercise with increased exercise capacity, improved diastolic function, physiological cardiac hypertrophy and increased cardiomyogenesis [167][168][169] . Even in mice expressing a proofreading-deficient version of Polg, endurance exercise for 5 months increases mitochondrial biogenesis and mitochondrial oxidative capacity and alleviates age-associated cardiomyopathy [170] . ...
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Progressive age-induced deterioration in the structure and function of the cardiovascular system involves cardiac hypertrophy, diastolic dysfunction, myocardial fibrosis, arterial stiffness, and endothelial dysfunction. These changes are driven by complex processes that are interconnected, such as oxidative stress, mitochondrial dysfunction, autophagy, inflammation, fibrosis, and telomere dysfunction. In recent years, the advances in research of cardiovascular aging, including the wide use of animal models of cardiovascular aging, elucidated an abundance of cell signaling pathways involved in these processes and brought into sight possible interventions, which span from pharmacological agents, such as metformin, sodium-glucose cotransporter 2-inhibitors, rapamycin, dasatinib and quercetin, to lifestyle changes.
... Altogether, these studies including ours help pave the way for the development of therapies that mitigate the severity of chronic diseases, such as neurodegenerative disorders and cardiovascular diseases. [64][65][66][67][68] Disturbance of circadian rhythms can negatively affect mental and physical health and is a well-known hallmark of aging. 69,70 Although previous reports demonstrated that physical activity could resynchronize the circadian clock, 71,72 little is known about whether circadian rhythms are regulators of cellular homeostasis and aging during exercise. ...
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Exercise benefits the whole organism, yet, how tissues across the body orchestrally respond to exercise remains enigmatic. Here, in young and old mice, with or without exercise, and exposed to infectious injury, we characterized the phenotypic and molecular adaptations to 12-month exercise across 14 tissues/organs at single-cell resolution. Overall, exercise protects tissues from infectious injury, although more effectively in young animals, and benefits aged individuals in terms of inflammaging suppression and tissue rejuvenation, with structural improvement in the central nervous system and systemic vasculature being most prominent. In vascular endothelial cells, we found that readjusting the rhythmic machinery via the core circadian clock protein BMAL1 delayed senescence and facilitated recovery from infectious damage, recapitulating the beneficial effects of exercise. Our study underscores the effect of exercise in reconstituting the youthful circadian clock network and provides a foundation for further investigating the interplay between exercise, aging, and immune challenges across the whole organism.
Heart failure (HF) with preserved ejection fraction (HFpEF) is currently a preeminent challenge for cardiovascular medicine. It has a poor prognosis, increasing mortality, and is escalating in prevalence worldwide. Despite accounting for over 50% of all HF patients, the mechanistic underpinnings driving HFpEF are poorly understood, thus impeding the discovery and development of mechanism-based therapies. HFpEF is a disease syndrome driven by diverse comorbidities, including hypertension, diabetes and obesity, pulmonary hypertension, aging, and atrial fibrillation. There is a lack of high-fidelity animal models that faithfully recapitulate the HFpEF phenotype, owing primarily to the disease heterogeneity, which has hampered our understanding of the complex pathophysiology of HFpEF. This review provides an updated overview of the currently available animal models of HFpEF and discusses their characteristics from the perspective of energy metabolism. Interventional strategies for efficiently utilizing energy substrates in preclinical HFpEF models are also discussed.
Cardiac aging is accompanied by changes in the heart at the cellular and molecular levels, leading to alterations in cardiac structure and function. Given today's increasingly aging population, the decline in cardiac function caused by cardiac aging has a significant impact on quality of life. Anti-aging therapies to slow the aging process and attenuate changes in cardiac structure and function have become an important research topic. Treatment with drugs, including metformin, spermidine, rapamycin, resveratrol, astaxanthin, Huolisu oral liquid, and sulforaphane, has been demonstrated be effective in delaying cardiac aging by stimulating autophagy, delaying ventricular remodeling, and reducing oxidative stress and the inflammatory response. Furthermore, caloric restriction has been shown to play an important role in delaying aging of the heart. Many studies in cardiac aging and cardiac aging-related models have demonstrated that Sestrin2 has antioxidant and anti-inflammatory effects, stimulates autophagy, delays aging, regulates mitochondrial function, and inhibits myocardial remodeling by regulation of relevant signaling pathways. Therefore, Sestrin2 is likely to become an important target for anti-myocardial aging therapy.
Aims: The prevalence of left ventricular (LV) diastolic and vascular dysfunction increases with age, eventually leading to heart failure with preserved ejection fraction (HFpEF). A preventive strategy is an unmet medical need. We and others reported previously on the beneficial effects of omega-3 fatty acid alpha linolenic acid (ALA) on cardiovascular disorders in animal models and translational studies. We now investigate whether long-term dietary ALA could prevent LV diastolic dysfunction and vascular aging in a murine model. Methods and results: Wild-type C57BL/6 J mice were fed a chow or ALA diet for 12 months, starting at 6 months of age. Here, we show that aged (~18 months) mice recapitulate major hallmarks of HFpEF, including LV diastolic dysfunction with preserved ejection fraction, impaired vascular function, cardiac fibrosis, arterial stiffening and inflammation, as well as elevated B-type natriuretic peptide (BNP). Long-term ALA supplementation upregulated the mitochondrial tricarboxylic acid enzyme Idh2 and the antioxidant enzymes SOD1 and Gpx1. It also has been associated with reduced inflammation and ECM remodeling, accompanied by a significant downregulation of fibrosis biomarkers MMP-2 and TGF-β in both cardiac and vascular tissues obtained from aged mice. Our data exhibited the preventive effects of dietary ALA against LV diastolic dysfunction, impaired vasorelaxation, cardiac fibrosis, inflammation and arterial stiffening in aged mice. Conclusions: We provide evidence and a simplified mechanistic insight on how long-term ALA supplementation is a successful strategy to prevent the development of age-related diastolic and vascular dysfunction.
Spontaneous and age-related amyloidosis has been reported in C57BL/6J mice; however, the biochemical characteristics of age-related amyloidosis remain unclear. Therefore, we herein investigated the age-related prevalence of amyloidosis, the types of amyloid fibril proteins, and the effects of amyloid deposition on renal function in C57BL/6J mice. The results obtained revealed a high incidence of amyloidosis in C57BL/6J mice originating from the Jackson laboratory as well as the deposition of large amounts of amyloid in the glomeruli of aged mice. We identified the amyloid fibril protein in C57BL/6J mice as wild-type apolipoprotein A-II. We induced renal amyloid deposition in 40-week-old mice, equivalent to that of spontaneous development in 80-week-old mice, to rule out the effects of aging, and revealed subsequent damage to kidney function by amyloid deposits. Furthermore, amyloid deposition in the mesangial region decreased podocyte density, compromised foot processes, and led to the accumulation of fibroblast growth factor 2 (FGF2) in glomeruli. Collectively, these results suggest that AApoAII deposition is a general pathology in aged C57BL/6J mice and is dependent on supplier colonies. Therefore, the effects of age-related amyloid deposition need to be considered in research on aging in mice.
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Heart failure with preserved ejection fraction (HFpEF) is one of the most complex and most prevalent cardiometabolic diseases in aging population. Age, obesity, diabetes, and hypertension are the main comorbidities of HFpEF. Microvascular dysfunction and vascular remodeling play a major role in its development. Among the many mechanisms involved in this process, vascular stiffening has been described as one the most prevalent during HFpEF, leading to ventricular-vascular uncoupling and mismatches in aged HFpEF patients. Aged blood vessels display an increased number of senescent endothelial cells (ECs) and vascular smooth muscle cells (VSMCs). This is consistent with the fact that EC and cardiomyocyte cell senescence has been reported during HFpEF. Autophagy plays a major role in VSMCs physiology, regulating phenotypic switch between contractile and synthetic phenotypes. It has also been described that autophagy can regulate arterial stiffening and EC and VSMC senescence. Many studies now support the notion that targeting autophagy would help with the treatment of many cardiovascular and metabolic diseases. In this review, we discuss the mechanisms involved in autophagy-mediated vascular senescence and whether this could be a driver in the development and progression of HFpEF.
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Heart failure with preserved ejection fraction (HFpEF) is a common syndrome with high morbidity and mortality for which there are no evidence-based therapies. Here we report that concomitant metabolic and hypertensive stress in mice—elicited by a combination of high-fat diet and inhibition of constitutive nitric oxide synthase using Nω-nitro-l-arginine methyl ester (l-NAME)—recapitulates the numerous systemic and cardiovascular features of HFpEF in humans. Expression of one of the unfolded protein response effectors, the spliced form of X-box-binding protein 1 (XBP1s), was reduced in the myocardium of our rodent model and in humans with HFpEF. Mechanistically, the decrease in XBP1s resulted from increased activity of inducible nitric oxide synthase (iNOS) and S-nitrosylation of the endonuclease inositol-requiring protein 1α (IRE1α), culminating in defective XBP1 splicing. Pharmacological or genetic suppression of iNOS, or cardiomyocyte-restricted overexpression of XBP1s, each ameliorated the HFpEF phenotype. We report that iNOS-driven dysregulation of the IRE1α–XBP1 pathway is a crucial mechanism of cardiomyocyte dysfunction in HFpEF.
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The number of persons with heart failure has continued to rise over the last several years. Approximately one-half of those living with heart failure have heart failure with preserved ejection fraction, but critical unsolved questions remain across the spectrum of basic, translational, clinical, and population research in heart failure with preserved ejection fraction. In this study, the authors summarize existing knowledge, persistent controversies, and gaps in evidence with regard to the understanding of heart failure with preserved ejection fraction. Our analysis is based on an expert panel discussion “Think Tank” meeting that included representatives from academia, the National Institutes of Health, the U.S. Food and Drug Administration, the Centers for Medicare & Medicaid Services, and industry.
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Loss of cardiomyocytes is a major cause of heart failure, and while the adult heart has a limited capacity for cardiomyogenesis, little is known about what regulates this ability or whether it can be effectively harnessed. Here we show that 8 weeks of running exercise increase birth of new cardiomyocytes in adult mice (~4.6-fold). New cardiomyocytes are identified based on incorporation of 15N-thymidine by multi-isotope imaging mass spectrometry (MIMS) and on being mononucleate/diploid. Furthermore, we demonstrate that exercise after myocardial infarction induces a robust cardiomyogenic response in an extended border zone of the infarcted area. Inhibition of miR-222, a microRNA increased by exercise in both animal models and humans, completely blocks the cardiomyogenic exercise response. These findings demonstrate that cardiomyogenesis can be activated by exercise in the normal and injured adult mouse heart and suggest that stimulation of endogenous cardiomyocyte generation could contribute to the benefits of exercise.
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Macrophages populate the healthy myocardium and, depending on their phenotype, may contribute to tissue homeostasis or disease. Their origin and role in diastolic dysfunction, a hallmark of cardiac aging and heart failure with preserved ejection fraction, remain unclear. Here we show that cardiac macrophages expand in humans and mice with diastolic dysfunction, which in mice was induced by either hypertension or advanced age. A higher murine myocardial macrophage density results from monocyte recruitment and increased hematopoiesis in bone marrow and spleen. In humans, we observed a parallel constellation of hematopoietic activation: circulating myeloid cells are more frequent, and splenic ¹⁸ F-FDG PET/CT imaging signal correlates with echocardiographic indices of diastolic dysfunction. While diastolic dysfunction develops, cardiac macrophages produce IL-10, activate fibroblasts, and stimulate collagen deposition, leading to impaired myocardial relaxation and increased myocardial stiffness. Deletion of IL-10 in macrophages improves diastolic function. These data imply expansion and phenotypic changes of cardiac macrophages as therapeutic targets for cardiac fibrosis leading to diastolic dysfunction.
Exercise intolerance is the cardinal symptom of heart failure (HF) and is of crucial relevance, because it is associated with a poor quality of life and increased mortality. While impaired cardiac reserve is considered to be central in HF, reduced exercise and functional capacity are the result of key patient characteristics and multisystem dysfunction, including aging, impaired pulmonary reserve, as well as peripheral and respiratory skeletal muscle dysfunction. We herein review the different modalities to quantify exercise intolerance, the pathophysiology of HF, and comorbid conditions as they lead to reductions in exercise and functional capacity, highlighting the fact that distinct causes may coexist and variably contribute to exercise intolerance in patients with HF.
Activin type II receptor (ActRII) ligands have been implicated in muscle wasting in aging and disease. However, the role of these ligands and ActRII signaling in the heart remains unclear. Here, we investigated this catabolic pathway in human aging and heart failure (HF) using circulating follistatin-like 3 (FSTL3) as a potential indicator of systemic ActRII activity. FSTL3 is a downstream regulator of ActRII signaling, whose expression is up-regulated by the major ActRII ligands, activin A, circulating growth differentiation factor-8 (GDF8), and GDF11. In humans, we found that circulating FSTL3 increased with aging, frailty, and HF severity, correlating with an increase in circulating activins. In mice, increasing circulating activin A increased cardiac ActRII signaling and FSTL3 expression, as well as impaired cardiac function. Conversely, ActRII blockade with either clinical-stage inhibitors or genetic ablation reduced cardiac ActRII signaling while restoring or preserving cardiac function in multiple models of HF induced by aging, sarcomere mutation, or pressure overload. Using unbiased RNA sequencing, we show that activin A, GDF8, and GDF11 all induce a similar pathologic profile associated with up-regulation of the proteasome pathway in mammalian cardiomyocytes. The E3 ubiquitin ligase, Smurf1, was identified as a key downstream effector of activin-mediated ActRII signaling, which increased proteasome-dependent degradation of sarcoplasmic reticulum Ca ²⁺ ATPase (SERCA2a), a critical determinant of cardiomyocyte function. Together, our findings suggest that increased activin/ActRII signaling links aging and HF pathobiology and that targeted inhibition of this catabolic pathway holds promise as a therapeutic strategy for multiple forms of HF.
Importance There are few effective treatments for heart failure with preserved ejection fraction (HFpEF). Short-term administration of inorganic nitrite or nitrate preparations has been shown to enhance nitric oxide signaling, which may improve aerobic capacity in HFpEF. Objective To determine the effect of 4 weeks’ administration of inhaled, nebulized inorganic nitrite on exercise capacity in HFpEF. Design, Setting, and Participants Multicenter, double-blind, placebo-controlled, 2-treatment, crossover trial of 105 patients with HFpEF. Participants were enrolled from July 22, 2016, to September 12, 2017, at 17 US sites, with final date of follow-up of January 2, 2018. Interventions Inorganic nitrite or placebo administered via micronebulizer device. During each 6-week phase of the crossover study, participants received no study drug for 2 weeks (baseline/washout) followed by study drug (nitrite or placebo) at 46 mg 3 times a day for 1 week followed by 80 mg 3 times a day for 3 weeks. Main Outcomes and Measures The primary end point was peak oxygen consumption (mL/kg/min). Secondary end points included daily activity levels assessed by accelerometry, health status as assessed by the Kansas City Cardiomyopathy Questionnaire (score range, 0-100, with higher scores reflecting better quality of life), functional class, cardiac filling pressures assessed by echocardiography, N-terminal fragment of the prohormone brain natriuretic peptide levels, other exercise indices, adverse events, and tolerability. Outcomes were assessed after treatment for 4 weeks. Results Among 105 patients who were randomized (median age, 68 years; 56% women), 98 (93%) completed the trial. During the nitrite phase, there was no significant difference in mean peak oxygen consumption as compared with the placebo phase (13.5 vs 13.7 mL/kg/min; difference, −0.20 [95% CI, −0.56 to 0.16]; P = .27). There were no significant between–treatment phase differences in daily activity levels (5497 vs 5503 accelerometry units; difference, −15 [95% CI, −264 to 234]; P = .91), Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (62.6 vs 61.9; difference, 1.1 [95% CI, −1.4 to 3.5]; P = .39), functional class (2.5 vs 2.5; difference, 0.1 [95% CI, −0.1 to 0.2]; P = .43), echocardiographic E/e′ ratio (16.4 vs 16.6; difference, 0.1 [95% CI, −1.2 to 1.3]; P = .93), or N-terminal fragment of the prohormone brain natriuretic peptide levels (520 vs 533 pg/mL; difference, 11 [95% CI, −53 to 75]; P = .74). Worsening heart failure occurred in 3 participants (2.9%) during the nitrite phase and 8 (7.6%) during the placebo phase. Conclusions and Relevance Among patients with HFpEF, administration of inhaled inorganic nitrite for 4 weeks, compared with placebo, did not result in significant improvement in exercise capacity. Trial Registration Identifier: NCT02742129
The lack of effective treatments for heart failure with preserved ejection fraction represents a large and growing unmet need in cardiology today. A critical obstacle to therapeutic innovation in heart failure with preserved ejection fraction has been the absence of animal models that accurately recapitulate the complexities of the human disease. Here, we propose that more comprehensive multiorgan system and functional phenotyping of preclinical models is essential if we are to maximize our chances of discovering and validating novel targets for effective therapeutic development in heart failure with preserved ejection fraction.
Heart failure (HF) with preserved ejection fraction (HFpEF) is a clinical syndrome associated with poor quality of life, substantial health-care resource utilization, and premature mortality. We summarize the current knowledge regarding the epidemiology of HFpEF with a focus on community-based studies relevant to quantifying the population burden of HFpEF. Current data regarding the prevalence and incidence of HFpEF in the community as well as associated conditions and risk factors, risk of morbidity and mortality after diagnosis, and quality of life are presented. In the community, approximately 50% of patients with HF have HFpEF. Although the age-specific incidence of HF is decreasing, this trend is less dramatic for HFpEF than for HF with reduced ejection fraction (HFrEF). The risk of HFpEF increases sharply with age, but hypertension, obesity, and coronary artery disease are additional risk factors. After adjusting for age and other risk factors, the risk of HFpEF is fairly similar in men and women, whereas the risk of HFrEF is much lower in women. Multimorbidity is common in both types of HF, but slightly more severe in HFpEF. A majority of deaths in patients with HFpEF are cardiovascular, but the proportion of noncardiovascular deaths is higher in HFpEF than HFrEF.
Exercise elicits coordinated multi-organ responses including skeletal muscle, vasculature, heart, and lung. In the short term, the output of the heart increases to meet the demand of strenuous exercise. Long-term exercise instigates remodeling of the heart including growth and adaptive molecular and cellular re-programming. Signaling pathways such as the insulin-like growth factor 1/PI3K/Akt pathway mediate many of these responses. Exercise-induced, or physiologic, cardiac growth contrasts with growth elicited by pathological stimuli such as hypertension. Comparing the molecular and cellular underpinnings of physiologic and pathologic cardiac growth has unveiled phenotype-specific signaling pathways and transcriptional regulatory programs. Studies suggest that exercise pathways likely antagonize pathological pathways, and exercise training is often recommended for patients with chronic stable heart failure or following myocardial infarction. Herein, we summarize the current understanding of the structural and functional cardiac responses to exercise as well as signaling pathways and downstream effector molecules responsible for these adaptations.