Postpartum cardiomyopathy (PPCM) is a disease of unknown etiology and exposes women to high risk of mortality after delivery. Here, we show that female mice with a cardiomyocyte-specific deletion of stat3 develop PPCM. In these mice, cardiac cathepsin D (CD) expression and activity is enhanced and associated with the generation of a cleaved antiangiogenic and proapoptotic 16 kDa form of the nursing hormone prolactin. Treatment with bromocriptine, an inhibitor of prolactin secretion, prevents the development of PPCM, whereas forced myocardial generation of 16 kDa prolactin impairs the cardiac capillary network and function, thereby recapitulating the cardiac phenotype of PPCM. Myocardial STAT3 protein levels are reduced and serum levels of activated CD and 16 kDa prolactin are elevated in PPCM patients. Thus, a biologically active derivative of the pregnancy hormone prolactin mediates PPCM, implying that inhibition of prolactin release may represent a novel therapeutic strategy for PPCM.
Abstract-The transcription factor signal transducer and activator of transcription 3 (STAT3) participates in a wide variety of physiological processes and directs seemingly contradictory responses such as proliferation and apoptosis. To elucidate its role in the heart, we generated mice harboring a cardiomyocyte-restricted knockout of STAT3 using Cre/loxP-mediated recombination. STAT3-deficient mice developed reduced myocardial capillary density and increased interstitial fibrosis within the first 4 postnatal months, followed by dilated cardiomyopathy with impaired cardiac function and premature death. Conditioned medium from STAT3-deficient cardiomyocytes inhibited endothelial cell proliferation and increased fibroblast proliferation, suggesting the presence of paracrine factors attenuating angiogenesis and promoting fibrosis in vitro. STAT3-deficient mice showed enhanced susceptibility to myocardial ischemia/reperfusion injury and infarction with increased cardiac apoptosis, increased infarct sizes, and reduced cardiac function and survival. Our study establishes a novel role for STAT3 in controlling paracrine circuits in the heart essential for postnatal capillary vasculature maintenance, interstitial matrix deposition balance, and protection from ischemic injury and heart failure. Key Words: mouse Ⅲ signal transduction Ⅲ angiogenesis Ⅲ ischemia Ⅲ heart failure A ctivation of signal transducer and activator of transcription 3 (STAT3) in the heart has been observed in acute myocardial infarction (MI), ischemic preconditioning, and pressure overload. [1][2][3] In this regard, activation of the stressresponsive Janus kinase (JAK)-STAT signaling pathway during ischemia/reperfusion (I/R) injury and MI has been proposed to provide protection against ischemic stress via transcriptional activation of cytoprotective genes. 1,4 Cell culture studies have ascribed some of the cytoprotective actions of the JAK-STAT pathway in cardiomyocytes specifically to STAT3 activation. 5 However, although STAT3 activation is clearly associated with an upregulation of a wide array of target genes in cardiomyocytes, it is unclear which of the reported cardiac responses associated with STAT3 activation are indeed required in vivo for controlling cardiac growth, function, tissue architecture, or protection against cardiovascular stress such as ischemic injury. Importantly, although increased circulating levels of interleukin (IL)-6 -related cytokines predict mortality in patients with heart failure and may enhance gp130 activation in the failing human heart, expression and phosphorylation levels of STAT3 are severely depressed in myocardium obtained from patients with dilated cardiomyopathy, 6 raising the possibility that decreased STAT3 activation may contribute to development of cardiac failure in patients.To elucidate the potential role of STAT3 in cardiac muscle and, in particular, for cardiac protection against physiological and pathophysiological stress, we created mice with a cardiomyocyte-restricted STAT3 deletion. Materials and...
Peripartum cardiomyopathy (PPCM) is a life-threatening heart disease developing towards the end of pregnancy or in the months following delivery in previously healthy women in terms of cardiac disease. Enhanced oxidative stress and the subsequent cleavage of the nursing hormone Prolactin into an anti-angiogenic 16 kDa subfragment emerged as a potential causal factor of the disease. We established a prospective registry with confirmed PPCM present in 115 patients (mean baseline left ventricular ejection fraction, LVEF: 27 ± 9 %). Follow-up data (6 ± 3 months) showed LVEF improvement in 85 % and full recovery in 47 % while 15 % failed to recover with death in 2 % of patients. A positive family history of cardiomyopathy was present in 16.5 %. Pregnancy-associated hypertension was associated with a better outcome while a baseline LVEF ≤ 25 % was associated with a worse outcome. A high recovery rate (96 %) was observed in patients obtaining combination therapy with beta-blocker, angiotensin-converting enzyme (ACE) inhibitors/angiotensin-receptor-blockers (ARBs) and bromocriptine. Increased serum levels of Cathepsin D, the enzyme that generates 16 kDa Prolactin, miR-146a, a direct target of 16 kDa Prolactin, N-terminal-pro-brain-natriuretic peptide (NT-proBNP) and asymmetric dimethylarginine (ADMA) emerged as biomarkers for PPCM. In conclusion, low baseline LVEF is a predictor for poor outcome while pregnancy-induced hypertensive disorders are associated with a better outcome in this European PPCM cohort. The high recovery rate in this collective is associated with a treatment concept using beta-blockers, ACE inhibitors/ARBs and bromocriptine. Increased levels of Cathepsin D activity, miR-146a and ADMA in serum of PPCM patients support the pathophysiological role of 16 kDa Prolactin for PPCM and may be used as a specific diagnostic marker profile.Electronic supplementary materialThe online version of this article (doi:10.1007/s00395-013-0366-9) contains supplementary material, which is available to authorized users.
AimsAn anti-angiogenic cleaved prolactin fragment is considered causal for peripartum cardiomyopathy (PPCM). Experimental and first clinical observations suggested beneficial effects of the prolactin release inhibitor bromocriptine in PPCM.Methods and resultsIn this multicentre trial, 63 PPCM patients with left ventricular ejection fraction (LVEF) ≤35% were randomly assigned to short-term (1W: bromocriptine, 2.5 mg, 7 days) or long-term bromocriptine treatment (8W: 5 mg for 2 weeks followed by 2.5 mg for 6 weeks) in addition to standard heart failure therapy. Primary end point was LVEF change (delta) from baseline to 6 months assessed by magnetic resonance imaging. Bromocriptine was well tolerated. Left ventricular ejection fraction increased from 28 ± 10% to 49 ± 12% with a delta-LVEF of + 21 ± 11% in the 1W-group, and from 27 ± 10% to 51 ± 10% with a delta-LVEF of + 24 ± 11% in the 8W-group (delta-LVEF: P = 0.381). Full-recovery (LVEF ≥ 50%) was present in 52% of the 1W- and in 68% of the 8W-group with no differences in secondary end points between both groups (hospitalizations for heart failure: 1W: 9.7% vs. 8W: 6.5%, P = 0.651). The risk within the 8W-group to fail full-recovery after 6 months tended to be lower. No patient in the study needed heart transplantation, LV assist device or died.ConclusionBromocriptine treatment was associated with high rate of full LV-recovery and low morbidity and mortality in PPCM patients compared with other PPCM cohorts not treated with bromocriptine. No significant differences were observed between 1W and 8W treatment suggesting that 1-week addition of bromocriptine to standard heart failure treatment is already beneficial with a trend for better full-recovery in the 8W group.Clinical trial registrationClinicalTrials.gov, study number: NCT00998556.
Background-Experimental studies indicate that interleukin-6 (IL-6)-related cytokines, signaling via the shared receptor gp130, Janus kinases (JAKs), and signal transducers and activators of transcription (STATs), provide a critical cardiomyocyte survival pathway in vivo. Little is known about the activation of this signaling pathway in the myocardia of patients with end-stage dilated cardiomyopathy (DCM). Methods and Results-We performed a comprehensive expression and activation analysis of IL-6 -related cytokines, receptors, signal transducers, and signal transduction inhibitors in left ventricular (LV) myocardia from patients with DCM (nϭ10) and non-failing (NF) donor hearts (nϭ5 Key Words: cardiomyopathy Ⅲ interleukins Ⅲ signal transduction D ilated cardiomyopathy (DCM) represents a common end-stage disease state of the myocardium in response to different environmental and genetic factors, a fact that has led to the proposition of shared signaling pathways for cardiac dilation and failure. 1 In this regard, a growing body of evidence indicates that interleukin-6 (IL-6)-related cytokines signaling via the shared receptor gp130 provide a critical myocyte survival pathway in vivo. Most notably, genetargeted mice with a cardiomyocyte-restricted deletion of gp130 develop massive cardiomyocyte apoptosis and dilated cardiomyopathy when subjected to biomechanical stress. 2 A prevailing concept predicts that an intricate balance between cardiomyocyte hypertrophy and apoptosis determines heart failure progression. 1 In this regard, the Janus kinases-signal transducers and activators of transcription (JAK-STAT) signaling pathway has been shown to mediate hypertrophic and cytoprotective effects of gp130 activation in cardiomyocytes. 2-8 IL-6 -related cytokines potently activate gp130, which in turn promotes tyrosine-phosphorylation (ie, activation) of JAKs and cytoplasmic latent transcription factors of the STAT family. 9 Signaling via gp130 and JAK-STAT is controlled in a negative-feedback fashion by a family of proteins referred to as suppressors of cytokine signaling, including SOCS1 and SOCS3. 10,11 Despite increasing evidence implicating IL-6 -related cytokines, gp130, and JAK-STAT as a critical myocyte survival pathway, little is known regarding expression and activation of this pathway in patients with DCM. In the present study, we have conducted a comprehensive expression and activation analysis of the gp130-JAK-STAT signaling cascade in left ventricular (LV) myocardia from patients with DCM. Methods Patient PopulationLV myocardium was obtained from patients undergoing heart transplantation because of end-stage DCM (nϭ10; mean age: 44Ϯ13 years; New York Heart Association functional classes III and IV; LV ejection fraction: 16Ϯ7%; LV end-diastolic diameter: 65Ϯ14 mm). ImmunohistochemistryImmunohistochemistry was performed on serial sections from NF and DCM hearts using antibodies from New England Biolabs (Beverly, Mass, JAK2), Cell Signaling Technology (STAT3), Biomeda (Foster City, Calif, skeletal muscle ␣-actin...
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