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UNIVERSITY OF OULU P .O. Box 8000 F I -90014 UNIVERSITY OF OULU FINLAND
A C T A U N I V E R S I T A T I S O U L U E N S I S
University Lecturer Tuomo Glumoff
University Lecturer Santeri Palviainen
Postdoctoral research fellow Sanna Taskila
Professor Olli Vuolteenaho
University Lecturer Veli-Matti Ulvinen
Planning Director Pertti Tikkanen
Professor Jari Juga
University Lecturer Anu Soikkeli
Professor Olli Vuolteenaho
Publications Editor Kirsti Nurkkala
ISBN 978-952-62-2028-4 (Paperback)ISBN 978-952-62-2029-1 (PDF)ISSN 0355-3221 (Print)ISSN 1796-2234 (Online)
U N I V E R S I TAT I S O U L U E N S I S
MEDICA
ACTAD
D 1481
AC
TAA
nnina Kelloniem
i
OULU 2018
D 1481
Annina Kelloniemi
NOVEL FACTORS REGULATING CARDIAC REMODELING IN EXPERIMENTAL MODELSOF CARDIAC HYPERTROPHY AND FAILURE
UNIVERSITY OF OULU GRADUATE SCHOOL;UNIVERSITY OF OULU,FACULTY OF MEDICINE;BIOCENTER OULU
ACTA UNIVERS ITAT I S OULUENS I SD M e d i c a 1 4 8 1
ANNINA KELLONIEMI
NOVEL FACTORS REGULATING CARDIAC REMODELING IN EXPERIMENTAL MODELS OF CARDIAC HYPERTROPHY AND FAILURE
Academic dissertation to be presented with the assent ofthe Doctoral Training Committee of Health andBiosciences of the University of Oulu for public defence inAuditorium F202 of the Faculty of Medicine (Aapistie 5 B),on 26 October 2018, at 12 noon
UNIVERSITY OF OULU, OULU 2018
Copyright © 2018Acta Univ. Oul. D 1481, 2018
Supervised byProfessor Heikki RuskoahoAssociate Professor Jaana Rysä
Reviewed byDocent Päivi LakkistoDocent Minna Kaikkonen-Määttä
ISBN 978-952-62-2028-4 (Paperback)ISBN 978-952-62-2029-1 (PDF)
ISSN 0355-3221 (Printed)ISSN 1796-2234 (Online)
Cover DesignRaimo Ahonen
JUVENES PRINTTAMPERE 2018
Kelloniemi, Annina, Novel factors regulating cardiac remodeling in experimentalmodels of cardiac hypertrophy and failure. University of Oulu Graduate School; University of Oulu, Faculty of Medicine; University ofOulu, Biocenter OuluActa Univ. Oul. D 1481, 2018University of Oulu, P.O. Box 8000, FI-90014 University of Oulu, Finland
Abstract
Cardiac loading induces left ventricular hypertrophy and cardiac remodeling which whenprolonged, leads to heart failure, a complex syndrome affecting approximately 1-2% of the adultpopulation of the Western world with a prevalence increasing with age. Pathological remodelinginvolves functional and structural changes that are associated with fetal gene expression,sarcomeric re-organization, hypertrophy of cardiomyocytes, fibrosis, inflammation, oxidativestress and impairment of metabolism.
The aim of this study was to investigate the role of three novel factors during the cardiacremodeling process with different experimental models of cardiac overload. Phosphatase and actinregulator 1 (Phacr1) expression was rapidly downregulated due to myocardial infarction (MI).Adenovirus-mediated Phactr1 overexpression changed the skeletal α-actin to cardiac α-actin ratioin both healthy and infarcted rat hearts and cultured cardiomyocytes. Phactr1 could regulate theactin isoform switch via the serum response factor (SRF). The expression of transforming growthfactor (TGF)- β-stimulated clone 22 (TSC-22) was rapidly induced by multiple hypertrophicstimuli and was also evident post-MI. In addition, TSC-22 could regulate collagen 3a1 expressionin the heart. The expression of retinal degeneration 3-like (Rd3l) was downregulated in responseto pressure overload and also downregulated post-MI. Rd3l knockout mice expressed increasedmyocyte hypertrophy and cardiac dysfunction in response to a transverse aortic constriction(TAC) induced pressure overload.
This thesis provides novel information about Phactr1, TSC-22 and Rd3l in load-inducedcardiac hypertrophy and remodeling. Collectively these studies increase our understanding of theregulatory mechanisms underlying the progression of heart failure.
Keywords: cardiac hypertrophy, cardiac remodeling, gene expression, myocardialinfarction
Kelloniemi, Annina, Sydämen uudelleenmuovautumista säätelevät uudet tekijätsydämen hypertrofian ja vajaatoiminnan kokeellisissa malleissa. Oulun yliopiston tutkijakoulu; Oulun yliopisto, Lääketieteellinen tiedekunta; Oulun yliopisto,Biocenter OuluActa Univ. Oul. D 1481, 2018Oulun yliopisto, PL 8000, 90014 Oulun yliopisto
Tiivistelmä
Sydämen kuormitus saa aikaan vasemman kammion liikakasvun eli hypertrofian ja sydämenuudelleenmuovautumisen, mikä pitkittyessään johtaa sydämen vajaatoimintaan. Sydämen vajaa-toiminta on monimutkainen oireyhtymä, josta länsimaissa kärsii noin 1-2 % aikuisväestöstä, jaesiintyvyys nousee iän myötä. Patologisessa uudelleenmuovautumisessa tapahtuu toiminnallisiaja rakenteellisia muutoksia, joihin liittyy muutoksia geenien ilmentymisessä, sarkomeerin uudel-leen järjestäytymistä, sydänlihassolujen koon kasvua, fibroosia, tulehdusta, oksidatiivista stres-siä ja aineenvaihdunnan huonontumista.
Tämän työn tarkoituksena oli tutkia kolmen uuden tekijän roolia sydämen uudelleenmuovau-tumisessa erilaisissa kokeellisissa sydämen kuormituksen malleissa. Fosfataasin ja aktiinin sää-telijä 1:n (Phactr1) ilmentyminen väheni nopeasti infarktin seurauksena. AdenovirusvälitteinenPhactr1:n ylituotanto muutti luusto- ja sydänlihasaktiinien isomuotojen suhdetta sekä terveessäettä infarktisydämessä, samoin viljellyissä sydänlihassoluissa. Phactr1 saattaa säädellä isomuo-tojen suhdetta seerumiresponsiivisen tekijän (SRF) avulla. Transformoituvan kasvutekijä β1:nstimuloima proteiini 22:n (TSC-22) ilmentyminen nousi nopeasti usean hypertrofisen stimuluk-sen seurauksena sekä infarktin jälkeen. Lisäksi TSC-22 voisi säädellä kollageeni 3a1:n ilmenty-mistä sydämessä. Retinan degeneroituvan proteiinin 3 kaltaisen tekijän (Rd3l) ilmentyminenväheni sekä painekuormituksen että infarktin seurauksena. Rd3l-poistogeenisillä hiirillä aortanahtauman aiheuttama painekuormitus sai aikaan lisääntynyttä sydänlihassolujen hypertrofiaa jasydämen toimintahäiriöitä.
Tämä väitöskirjatutkimus tuo uutta tietoa Phactr1-, TSC-22- ja Rd3l-geeneistä kuormituksenaiheuttamassa sydämen hypertrofiassa ja uudelleenmuovautumisessa. Nämä tulokset auttavatosaltaan ymmärtämään monimutkaisia molekyylitason mekanismeja, jotka johtavat sydämenvajaatoiminnan kehittymiseen.
Asasanat: geenien ilmentyminen, hypertrofia, infarkti, sydämen uudelleen-muovautuminen
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Acknowledgements
This work was carried out at the Department of Pharmacology and Toxicology,
Research Unit of Biomedicine, University of Oulu. I owe my deepest gratitude for
my supervisors Professor Heikki Ruskoaho and Associate Professor Jaana Rysä.
Heikki’s optimism, enthusiasm and vast knowledge of science is impressive. I am
very grateful to him for giving me the possibility to do research in his dynamic
research group in well-equipped environment. Jaana is acknowledged for her
excellent guidance and endless encouragement. Especially I am grateful for her
support in daily practical scientific matters and for always finding time to help.
Jaana’s contribution has been indispensable to this project.
I wish to thank Professor Emeritus Olavi Pelkonen and Professor Jukka
Hakkola, the former and current heads of the department for providing an inspiring
and relaxed atmosphere in which to work.
I thank Docents Päivi Lakkisto and Minna Kaikkonen-Määttä for their critical
review of the thesis and for their constructive comments. I also thank Ewen
MacDonald for excellent revision of my English and Anna Vuolteenaho for
revising the Finnish abstract.
I am grateful to all my co-authors Professor Olle Melander, Professor Thomas
Hedner, Professor Risto Kerkelä, Raija Soininen, Raisa Serpi, Zoltan Szabo, Juha
Näpänkangas, Jani Aro, Pauli Ohukainen, Erja Mustonen, Leena Kaikkonen, Elina
Koivisto, Olli Tenhunen, Margret Leosdottir and Zsolt Bagyura for their scientific
contribution.
I owe my gratitude to Sirpa Rutanen, Kati Lampinen, Marja Arbelius, Kaisa
Penttilä, Kirsi Salo and Pirjo Korpi for their skillful assistance and guidance in the
laboratory. Especially Kati’s contribution has been essential for completion of the
projects. Erja Tomperi and Mirja Vahera are also acknowledged for their technical
assistance with immunohistochemistry. I wish to thank the personnel at the
Laboratory Animal Centre and at the Biocenter Oulu Transgenic core facility. I am
also grateful for Raija Hanni, Esa Kerttula, Marja Räinä and Pirkko Viitala for
taking care of all the practical matters in the department.
All the past and present members of our research group are thanked for their
collaboration, company and help. Alicia Jurado Acosta, Leena Kaikkonen, Elina
Koivisto, Erja Mustonen, Virva Pohjolainen and Laura Vainio deserve special
thanks for their joyful company during unforgettable congress trips. Pauli
Ohukainen is greatly acknowledged for his invaluable friendship, support and
optimism that have helped me to overcome the final obstacles of this project. I
8
warmly thank Tarja Alakoski, Jani Aro, Sini Kinnunen, Anna-Maria Kubin, Hanne
Luosujärvi, Johanna Magga, Anne-Mari Moilanen, Ábel Perjés, Tuomas Peltonen,
Raisa Serpi, Zoltan Szabo, Hanna Säkkinen, Olli Tenhunen, Heikki Tokola, Anna-
Maria Tolonen and Maria Tölli for their excellent company in the lab, as well as
during the lunch breaks. Other colleagues in Farmis are warmly acknowledged as
well.
I cannot express enough my gratitude to all my friends. In particular, friendship
of Kristiina, Ari-Matti as well as Suvi, Sami and the other members of ”Kuukkelit”
has brought joy and meaning for my life. Thank you for persuading me out of lab
to enjoy outdoor activities and to hilarious social events.
I owe my deepest gratitude to my parents Marita and Pentti for their love and
care throughout my life as well as my dear sister Maaria and her family for all the
joy and support. Especially my nephew’s lovely and sunny smile makes me forget
all my worries. Finally, I am grateful to my ex-husband Antti for his friendship and
support for so many years. This project has been yours as much as mine.
This work was financially supported by the Academy of Finland (Center of
Excellence funding), Aarne Koskelo Foundation, Biocenter Oulu, the Finnish
Foundation for Cardiovascular Research, Ida Montin Foundation, Inkeri and Mauri
Vänskä Foundation, Orion Research Foundation and Sigrid Jusélius Foundation.
Oulu, August 2018 Annina Kelloniemi
9
Abbreviations
ACE angiotensin converting enzyme
Ang angiotensin
ANP atrial natriuretic peptide
AT1R angiotensin type 1 receptor
BNP B-type natriuretic peptide
BP blood pressure
CAD coronary artery disease
cGMP cyclic guanosine monophosphate
CMKII calcium-calmodulin-dependent kinase
COL collagen
DCM dilated cardiomyopathy
DN dominant negative
ECM extracellular matrix
ERK extracellular signal-regulated kinase
ESC European Society of Cardiology
EST expressed sequence tag
ET-1 endothelin-1
FS fractional shortening
GATA4 GATA binding protein 4
GPCR G protein-coupled receptor
gp130 glycoprotein 130
GWAS genome-wide association study
HCM hypertrophic cardiomyopathy
HDACs histone deacetylases
HF heart failure
HFpEF heart failure with preserved ejection fraction
HFrEF heart failure with reduced ejection fraction
HUVEC human umbilical vascular endothelial cell
IL interleukin
IP3 inositol triphosphate
JAK/STAT the janus kinase/signal transducers and activators of transcription
JNK c-jun NH2-terminal kinase
LV left ventricle
LVH left ventricular hypertrophy
LVEF left ventricular ejection fraction
10
MAPK mitogen-activated protein kinase
MAPKK mitogen-activated protein kinase kinase
MAPKKK MAPK kinase kinase
MEF-2 myocyte enhancer factor 2
MHC myosin heavy chain
MI myocardial infarction
MMP matrix metalloproteinase
MRTF myocardin-related transcription factor
NFAT calcineurin/nuclear factor of activated T cells
NRVMs neonatal rat ventricular myocytes
PAI-1 plasminogen activator inhibitor-1
PDE5A phosphodiesterase 5A
PHACTR1 phosphatase and actin regulator 1
PKC protein kinase C
PLC phospholipase C
RAA renin-angiotensin-aldosterone
Rd3l retinal degeneration 3-like
SERCA2 sarcoplasmic reticulum Ca2+ -ATPase
SHR spontaneously hypertensive rat
SNP single nucleotide polymorphism
SRE serum response elements
SRF serum response factor
STAT signal transducer and activator of transcription
TAC transverse aortic constriction
TGF transforming growth factor
TSC transforming growth factor β-stimulated clone
VEGF vascular endothelial growth factor
VHD valvular heart disease
11
List of original publications
This thesis is based on the following publications, which are referred throughout
the text by their Roman numerals:
I Kelloniemi A., Szabo Z., Serpi R., Näpänkangas J., Ohukainen P., Tenhunen O., Kaikkonen L., Koivisto E., Bagyura Z., Kerkelä R., Leosdottir M., Hedner T., Melander O., Ruskoaho H.*, Rysä J.* (2015). The early-onset myocardial infarction associated PHACTR1 gene regulates skeletal and cardiac alpha-actin gene expression. PLoS ONE 10(6). http://doi.org/10.1371/journal.pone.0130502.
II Kelloniemi A., Aro J., Näpänkangas J., Koivisto E., Mustonen E., Ruskoaho H., Rysä J. (2015). TSC-22 up-regulates collagen 3a1 gene expression in the rat heart. BMC Cardiovascular Disorders, 15(1). http://doi.org/10.1186/s12872-015-0121-2.
III Kelloniemi A., Szabo Z., Serpi R., Aro J., Soininen R., Ruskoaho H.*, Rysä J.* Genetic retinal degeneration 3-like (Rd3l) deficiency induces cardiac dysfunction in response to pressure overload. Manuscript.
* equal contribution.
12
13
Contents
Abstract
Tiivistelmä
Acknowledgements 7 Abbreviations 9 List of original publications 11 Contents 13 1 Introduction 15 2 Review of the literature 17
2.1 Heart failure ............................................................................................ 17 2.1.1 Coronary artery disease and myocardial infarction ...................... 18 2.1.2 Hypertension ................................................................................ 19 2.1.3 Other causes for heart failure ....................................................... 20
2.2 Cardiac remodelling ................................................................................ 21 2.2.1 Cardiac fibrosis ............................................................................. 24
2.3 Cardiac hypertrophy ................................................................................ 29 2.3.1 Cardiac hypertrophic stimuli ........................................................ 30 2.3.2 Intracellular signalling pathways .................................................. 31 2.3.3 Fetal gene program ....................................................................... 33 2.3.4 Actin proteins ............................................................................... 35 2.3.5 Phosphatase and actin regulatory proteins .................................... 37 2.3.6 Transcription factors in cardiac hypertrophy ................................ 39
2.4 Identifying genetic susceptibility and molecular markers for
heart failure ............................................................................................. 42 2.4.1 Genome-wide association studies ................................................. 42 2.4.2 Genome-wide gene expression profiling studies .......................... 45
3 Aims of the research 49 4 Materials and methods 51 5 Results and discussion 53
5.1 Phactr1 expression is rapidly reduced in experimental MI (I) ................ 53 5.2 Phactr1 regulates skeletal α-actin to cardiac α-actin switch (I) ............... 53 5.3 SRF DNA binding activity is enhanced due to Phactr1
overexpression in vitro (I) ....................................................................... 56 5.4 The effects of Phactr1 gene delivery on cardiac function and
structure in normal and infarcted hearts (I) ............................................. 57
14
5.5 MI associated PHACTR1 allele is not associated with cardiac
dysfunction in humans (I) ....................................................................... 57 5.6 TSC-22 is up-regulated by multiple hypertrophic stimuli and
post-MI (II) ............................................................................................. 59 5.7 Reduced TSC-22 expression levels after long-term treatment of
heart failure with metoprolol and hypertension with metoprolol
or losartan (II) ......................................................................................... 62 5.8 Hypertrophic stimuli inducible signalling pathways regulating
TSC-22 gene expression (II) ................................................................... 62 5.9 The effect of TSC-22 overexpression on cardiac gene expression
in vivo (II) ................................................................................................ 63 5.10 Rd3l gene expression and tissue distribution (III) ................................... 64 5.11 Rd3l expression levels in experimental models of hypertension
and MI in rats (III) ................................................................................... 65 5.12 Generation of the Rd3l knockout mouse line (III) .................................. 65 5.13 The effects of hemodynamic pressure overload on Rd3l-deficient
mice (III) ................................................................................................. 65 6 Summary and conclusions 69 References 71 Original articles 95
15
1 Introduction
The main function of the heart is to maintain a blood circulation to meet the body´s
needs. Cardiac remodeling is an adaptive process which occurs when the heart
responds to altered demands. Cardiac remodeling involves many structural and
functional changes ranging from those occurring at the cellular level to those
involving the entire left ventricle. Pathological stimuli, such as increased cardiac
load, can lead to a remodeling process which is characterized by the hypertrophic
growth of cardiomyocytes, initiation of fetal gene programs, alterations in the
extracellular matrix (ECM), energy metabolism and cardiac contractility. Initially,
cardiac remodeling is considered to be a compensatory mechanism to maintain
cardiac output but it becomes maladaptive when prolonged such as happens in
pathological processes and it can eventually lead to heart failure. The main causes
of heart failure are chronic hypertension and myocardial infarction (MI) (Mann,
Barger, & Burkhoff, 2012; Wu et al., 2017).
The main triggers of cardiac hypertrophy are stretch-sensitive mechanisms and
excessive neurohumoral activation, including the sympathetic nervous system, the
renin-angiotensin-aldosterone (RAA) system, vasoactive peptides and vasopressin
(van Berlo, Maillet, & Molkentin, 2013). These stimuli activate complex
intracellular signaling pathways leading to the triggering of several transcription
factors and altered gene expression. One early response to these hypertrophic
stimuli involves the activation of immediate-early genes such as c-fos, c-jun and
egr-1 (Rysä, Tokola, & Ruskoaho, 2018). The early response phase is followed by
the reactivation of fetal gene program including the induction of atrial natriuretic
peptide (ANP) and B-type natriuretic peptide (BNP) expression (Kerkelä, Ulvila,
& Magga, 2015), and a switch to fetal isoforms of contractile sarcomeric proteins
such as cardiac α-actin and α-myosin heavy chain (α-MHC) being replaced by
skeletal α-actin and β-MHC, respectively (Burchfield, Xie, & Hill, 2013; Omura et
al., 2000; Taegtmeyer, Sen, & Vela, 2010).
Despite the treatment available, which currently focus on improving the
prognosis of the patient and relief of symptoms, approximately 50% of patients
suffering from HF die within 5 years of diagnosis. Although there is an ever-
expanding knowledge of the molecular mechanisms involved in LVH and HF, there
is still a need to identify new target molecules in order to develop novel diagnostic
tools and therapies. Previously, DNA microarray techniques have been used to
reveal several novel genes associated with the transition from LVH to HF (Rysa,
Leskinen, Ilves, & Ruskoaho, 2005) as well as novel mechanical stretch responsive
16
genes in cardiomyocytes (Rysä et al., 2018). These dysregulated genes include
transforming growth factor (TGF)-β-stimulated clone 22 (TSC-22), expressed
sequence tag (EST), currently known as retinal degeneration 3-like (Rd3l) and
phosphatase and actin regulator 1 (Phactr1). In addition, several genome-wide
association studies (GWAS)s have associated the PHACTR1 locus with coronary
artery disease (CAD) and MI (Consortium, 2009; Hager et al., 2012; Lu et al., 2012;
Matsuoka et al., 2015; Odonnell et al., 2011; Patel et al., 2012; Jessica van Setten
et al., 2013). The physiological role of these three load-inducible factors in the heart
is still unclear.
The aim of the present study was to investigate the expression of Phactr1, TSC-
22 and Rd3l in cardiac hypertrophy and left ventricular (LV) remodeling. The
expressions of Phactr1 and TSC-22 both at the mRNA and protein level were
studied in vivo in experimental models of pressure overload and myocardial
infarction. Direct myocardial effects of Phactr1 and TSC-22 gene transfer were also
evaluated. In addition, the mechanisms regulating their expression and the effects
of their overexpression were studied in vitro in cultured cardiomyocytes. Finally,
an Rd3l knockout mouse line was generated in order to clarify the function of Rd3l
in the response to pressure overload.
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2 Review of the literature
2.1 Heart failure
Heart failure is a complex syndrome in which ventricular filling or the ejection of
blood has become impaired as a result of an abnormality in cardiac structure or
function. Impairment of pumping efficiency can result from several causes that
vary in different parts of the world but the main diseases leading to HF are coronary
artery disease with myocardial infarction and chronic hypertension; other causes
are valvular heart disease (VHD), arrhythmias and cardiomyopathies. This chapter
is based on American Heart Association’s and European Society of Cardiology’s
(ESC) guidelines (McMurray et al., 2012; Yancy et al., 2013) for the treatment and
diagnosis of HF unless otherwise stated.
In the Western world, approximately 1-2% of the adult population suffers from
HF; the prevalence increases with age, being ≥ 10% among people 70 years or older.
Although the survival of HF after diagnosis has improved during the past couple of
decades, the mortality rates are still dismal with approximately every second patient
dying within 5 years of diagnosis. (Mozaffarian et al., 2016).
Although disorders of the pericardium, myocardium, endocardium, heart
valves or major blood vessels or some metabolic abnormalities can lead to HF, the
symptoms experienced by most patients with HF result from impaired LV function.
Patients suffering from HF typically display symptoms like shortness of breath and
fatigue, which may limit exercise tolerance, and cause ankle swelling. The
diagnosis of HF can be challenging, especially in the early stages, and should be
made based on a careful history and physical examination. There are several
diagnostic tests to diagnose HF e.g. echocardiography and the determination of the
plasma levels of natriuretic peptides, ANP and BNP.
Left ventricular ejection fraction (LVEF) is important in the diagnosis of HF
with the normal LVEF being ≥50-55%. HF can develop even though LVEF is
preserved or reduced. Depending on guidelines, the definitions of HF with reduced
EF (HFrEF) and HF with preserved EF (HFpEF) have varied. According to ESC’s
present guideline (Ponikowski et al., 2016), HFrEF is commonly defined as HF
with LVEF <40%. HF with preserved EF (HFpEF) is typically considered as ≥50%.
The diagnosis of HFpEF is more difficult and it has been proposed that the
incidence of HFpEF is increasing since more and more patients being hospitalized
with HF have HFpEF. As a group, HFpEF patients are older and more often female
18
and obese with more severe hypertension, anemia and atrial fibrillation than those
with HFrEF. They are also less likely to have coronary heart disease and they enjoy
a better prognosis compared to those with HFrEF. Those patients with an LVEF
ranging from 40 to 49% represent a grey area between HFrEF and HFpEF. In the
European guideline, (Ponikowski et al., 2016), this group is identified as HF with
mid-range EF.
Current treatment options for HF include pharmacological therapy, lifestyle
modifications, implantation of a left or bi-ventricular assist device and heart
transplantation. Angiotensin converting enzyme inhibitors, angiotensin II receptor
blockers and β-blockers improve the prognosis of the patients and relieve their
symptoms. Furthermore, diuretics, aldosterone antagonists and digoxin have also
been used to treat HF (Kemp & Conte, 2012; McMurray et al., 2012). Promisingly,
the combination of neprilysin inhibition with valsartan (sacubitril + valsartan) has
been claimed to exert beneficial effects on congestive heart failure (McMurray et
al., 2014).
2.1.1 Coronary artery disease and myocardial infarction
Coronary artery disease (also known as coronary heart disease) develops when the
heart’s arteries have a build-up of plaque on their inner walls and become hardened
and narrowed. As a consequence, there is a reduction in the flow of blood, nutrients
and oxygen to the myocardium. With time, even as long as decades, some plaques
may become unstable and rupture leading to thrombosis and arterial occlusion
(Libby, 2012). Myocardial infarction is defined as the death of cardiomyocytes due
to prolonged ischemia (Montecucco, Carbone, & Schindler, 2015). Because of their
high sensitivity, troponins T and I are used as specific biochemical markers for
cardiac damage since after a myocardial injury, troponin is released within 2-4
hours and this elevated concentration persists for up to 10-21 days to allow
diagnosis (Korff, Katus, & Giannitsis, 2006). In addition to the elevation in these
biochemical markers, myocardial infarction is characterized by ischemic symptoms
and electrocardiographic changes (Roger, 2007).
In the US, the prevalence of CAD among adults (≥ 20 years of age) is 5.0 %
for women and 7.6 % for men (Mozaffarian et al., 2016). The incidence of MI has
been evaluated in several cohort studies. When estimated according to 100000
adults, the overall incidence has been 205 in the Olmsted County Study (Arciero et
al., 2004; Roger et al., 2002) and 244 in the Worcester Heart Attack Study
(Goldberg, Yarzebski, Lessard, & Gore, 1999). The sex-specific incidence in the
19
Atherosclerosis Risk in Communities study was 190 for women and 410 for men
(Rosamond et al., 1998). The effect of ethnicity has been evaluated in the Corpus
Christi Study (Goff et al., 1997). The incidence in Mexican American women has
been 354 and 486 for men. In non-Hispanic White individuals, the incidence has
been 224 for women and 346 for men. The prevalence of CAD in Finland can be
estimated from drug register data (Stable coronary artery disease: Current Care
Guidelines, 2015); almost 181 000 person were prescribed drugs for the treatment
of stable CAD in Finland in 2013.
CAD is the most common cause of HF and in 63 % of patients with reduced
EF, HF is preceded by CAD (Lee et al., 2009), although hypertension and diabetes
are contributing factors in many cases. Patients with HF and LV systolic
dysfunction after myocardial infarction have a higher risk for cardiac rupture and
arrest, ventricular arrhythmias, recurrent myocardial infarction, stroke, longer
hospitalizations and death than patients without HF and LV systolic dysfunction
post-MI (Minicucci, Azevedo, Polegato, Paiva, & Zornoff, 2011).
Acute MI triggers changes in ventricular geometry and structure, leading to a
rapid decline in systolic function. Prolonged ischemia leads to necrosis and
apoptosis of cardiomyocytes. Since the adult heart has only a limited regenerative
capacity, the infarcted myocardium heals through the formation of a scar. Early
cardiac remodelling is characterized by a progressive ventricular dilation, increased
wall stress and hypertrophy of the remaining viable myocytes. The size of the
infarct and the severity of early remodelling determine the progress of ventricular
dysfunction and the development of chronic HF (Jugdutt, 2012).
Patients who develop signs of HF soon after infarction, tend to have a reduced
tolerance to ischemic injury due to pre-existent comorbidities such as recurrent
ischemia and diabetes. Infarct size, mechanical complications and myocardial
stunning are the major causes of HF during a patient’s hospital stay. Usually
myocyte loss, a hibernating myocardium and ventricular remodeling are related to
the development of HF after the patient has been discharged from the hospital
(Minicucci et al., 2011).
2.1.2 Hypertension
Hypertension is commonly defined as blood pressure (BP) values ≥140/90 mmHg.
The same values are used to diagnose young, middle-aged and elderly subjects,
excluding children and teenagers (Mancia et al., 2013). In the NHANES survey,
the prevalence of hypertension was estimated to be 32.6 % among US adults (≥20
20
years of age). Until 45 years of age, men are more likely than women to have
hypertension. Between the ages of 45 to 54 and 55 to 64 years, there are no
differences between the sexes but from 65 years of age, a higher percentage of
women than men have hypertension. The lifetime risk of HF is twice as high for
people with BP >160/90 mm Hg when compared to those with BP <140/90 mm Hg
(Mozaffarian et al., 2016). In Finland, it is estimated that 2 million individuals in
the adult population suffer from hypertension with approximately one million of
them taking hypertension medication (Hypertension: Current Care Guidelines,
2014).
Hypertension precedes HF in 26 % of patients. In 19 % of HF patients with
reduced EF, hypertension is present before the diagnosis; the corresponding value
for those with preserved EF is 36 % (Lee et al., 2009). However, hypertension can
contribute to HF via indirect mechanisms since it is a risk factor for atherosclerosis
and MI. In particular, in the elderly and in women, hypertension accounts for a
greater proportion of HF cases (Gudmundsdottir, Høieggen, Stenehjem, Waldum,
& Os, 2012).
Chronic hypertension, i.e. a condition present for decades, is a primary
precursor of LVH, which can lead to ventricular dysfunction and eventually to HF.
Diastolic dysfunction has been characterized with suboptimal ventricular filling
caused by insufficient LV relaxation without any change in ventricular compliance.
Hypertension induced diastolic dysfunction can also result from myocardial
fibrosis with collagen accumulation and changes in the shape of the heart’s
chambers (Hill & Olson, 2009).
Hypertension increases the risk for HF in all age groups and the lifetime risk
for HF is double in individuals with BP >140/90 mm Hg when compared to those
with BP <140/90 mm Hg. Therefore, early diagnosis and treatment of hypertension
can effectively prevent further complications.
2.1.3 Other causes for heart failure
LV remodelling occurs in several clinical conditions. In addition to myocardial
infarction and hypertension, valvular heart disease and cardiomyopathies can cause
HF. Valvular heart disease precedes HF in 8% of patients (Lee et al., 2009). Calcific
aortic stenosis and mitral valve regurgitation are the most common types of VHD
in the Western world (Vahanian et al., 2012). Calcific aortic stenosis is a progressive
disease causing a chronic pressure overload that further contributes to LV
21
remodelling (Lindman, Bonow, & Otto, 2013) whereas mitral regurgitation leads
to remodelling by increasing volume overload in LV (Jessup & Brozena, 2003).
Based on the structural and functional changes occurring in the heart, genetic
cardiomyopathies that may cause HF are classified into dilated cardiomyopathy
(DCM), hypertrophic cardiomyopathy (HCM), arrhythmogenic cardiomyopathy
and restrictive cardiomyopathy. Although genetic cardiomyopathies cause only a
small proportion of all HF cases, genetic cardiomyopathies are a common source
of morbidity and mortality in children and teenagers, with the prevalence being
approximately 40%. Depending of the type of cardiomyopathy, the genetic
background varies but typically mutations leading to cardiomyopathies are found
in the genes encoding sarcomeric, cell adhesion, transmembrane and nuclear
proteins (Cahill, Ashrafian, & Watkins, 2013).
In addition, arrhythmias and damage to the myocardium as a result of infection,
inflammation or chronic abuse of cardiotoxic substances (e.g. alcohol) can lead to
HF (McMurray et al., 2012; Yancy et al., 2013).
2.2 Cardiac remodelling
The heart has various dynamic mechanisms to help maintain its function in
response to altered demands. Cardiac remodeling is characterized by alterations in
the heart’s size, shape, structure and function which range from the cellular level to
those involving the entire left ventricle; these changes are regulated by mechanical,
neurohormonal and genetic factors. Diverse pathological (e.g. chronic hypertension,
MI, cardiomyopathy or VHD) or physiological stimuli (e.g. growth, pregnancy and
exercise) can increase the workload for the heart, leading to its remodelling and
hypertrophic growth which reduces ventricular wall stress and maintains or even
augments pump function (Mann et al., 2012; Sutton & Sharpe, 2000). Most adult
cardiomyocytes seem to have a limited proliferation capacity, so the heart responds
to increased demands by enlarging the size of the cardiomyocytes. Physiological
cardiac remodeling is a highly orchestrated and reversible process resulting in
decreased cardiac wall stress, increased pumping efficiency and vascularization
with an increase in the number of capillaries (Shimizu & Minamino, 2016).
Pathological remodeling, however, is an irreversible process and when prolonged,
it leads to maladaptive alterations and HF (Fig. 1). In pressure overload, such as in
hypertension or aortic stenosis, a reduction in wall stress is achieved by concentric
hypertrophy which leads to an increase in thickness of the free wall and septum. In
volume overload due to MI or dilated cardiomyopathy, the loss of cardiomyocytes
22
leads to rearrangement of the surviving cardiomyocytes and eccentric hypertrophy
with greater ventricular volumes and subsequent/partial ventricular dilatation.
Pathological stimuli can activate the innate immune system and trigger
inflammation. A short-term inflammatory response can be beneficial for cardiac
repair of damaged tissue but a prolonged inflammatory reaction extends the damage,
induces fibrosis and leads to maladaptive remodeling (Suthahar, Meijers, Silljé, &
de Boer, 2017). The remodeling involves altered gene expression and disturbances
in protein synthesis and cellular metabolism threatening the survival of
cardiomyocytes as well as changes in the ECM and angiogenesis. Ventricular
remodeling is a progressive response; initially it is a compensatory process but
ultimately it becomes detrimental and leads to LV wall thinning and dilatation
(Mann et al., 2012; Wu et al., 2017). Unlike physiological cardiac remodeling,
pathological remodeling is not associated with any increase in myocardial capillary
density proportional to the increased cardiac mass, and capillary rarefaction is one
important feature in the development of HFpEF (Hoenig, Bianchi, Rosenzweig, &
Sellke, 2008; Shimizu & Minamino, 2016).
Cardiac remodeling is accompanied by oxidative stress and the increased
generation of reactive oxygen species as well as disturbed calcium homeostasis
leading to mis- and/or unfolded proteins; this is referred to as endoplasmic
reticulum stress and to cellular autophagy/apoptosis (Wu et al., 2017). During
remodeling, there are also changes in cardiac energy metabolism. In the normal
heart, approximately 70% to 90% of cardiac energy is produced by the oxidation
of fatty acids, with the remaining 10% to 30% mostly originating from the
oxidation of glucose and lactate. Peroxisome proliferator-activated receptors
(PPARs) with estrogen-related receptor are important long-term regulators of
cardiac fatty acid metabolism in the normal heart. Most of the models of cardiac
hypertrophy and failure have revealed reduced cardiac use of fatty acids. However,
there are more variations in glucose use between different models of HF. The stage
of progression and the pathogenesis of the HF may exert an influence on the
observed changes in glucose metabolism (reviewed in Doenst, Nguyen, & Abel,
2013).
Cardiac remodeling involves mitochondrial dysfunction which is characterized
by abnormally high levels of mitochondrial reactive oxygen species and
downregulation of the genes maintaining normal mitochondrial biogenesis, such as
peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α)
(Azevedo, Minicucci, Santos, Paiva, & Zornoff, 2013; Schirone et al., 2017).
23
Disturbed calcium homeostasis is a remarkable feature of the compensatory
hypertrophy and heart failure. Cellular calcium cycling is a highly orchestrated,
essential process underpinning normal cardiac contractility being regulated by β-
adrenergic signaling. Calcium-induced calcium release from the sarcoplasmic
reticulum leads to elevated intracellular free Ca2+ concentration and triggers a
contraction of the cardiomyocyte. Relaxation is necessary to allow a new
contraction and therefore most of the cytosolic Ca2+ is pumped back into the
sarcoplasmic reticulum to be released again during a new contraction (Mayourian
et al., 2018). A major cause for impaired Ca2+ signaling and reduced contractility is
the down-regulation of the sarcoplasmic reticulum Ca2+ -ATPase 2 (SERCA2)
which is a key component participating in Ca2+ uptake in sarcoplasmic reticulum
(Barry, Davidson, & Townsend, 2008; Cabassi & Miragoli, 2017).
Fig. 1. Remodeling of cardiac tissue due to pathophysiological stimuli and the
progression to heart failure. Pathological stimuli, such as excessive mechanical load
or myocardial infarction can lead to multiple molecular and cellular processes
contributing to ventricular remodelling. Mechanical stress and neurohumoral activation
trigger hypertrophy of cardiomyocytes. Cardiomyocytes are lost through necrosis,
apoptosis and autophagy. Changes in the ECM leads to fibrosis. Remodeling includes
activation of fetal gene program, angiogenesis and changes in energy metabolism.
Impaired calcium cycling is a hallmark of HF. Modified from Burchfield, Xie, & Hill, 2013.
24
2.2.1 Cardiac fibrosis
Cardiac fibrosis is a process which involves collagen accumulation leading to
structural changes in heart and eventually impaired cardiac function (Krenning,
Zeisberg, & Kalluri, 2010). The cardiac ECM is composed of collagens I and III,
the former being the most abundant type of collagen in the heart,
glycosaminoglycans, glycoproteins and proteoglycans (Kong, Christia, &
Frangogiannis, 2014). Normal ECM provides structural support for
cardiomyocytes and in addition distributes the contractile forces through the
cardiac tissue and mediates electric conduction. The ECM consists of an
endomysium, perimysium and epimysium which surround the myocytes and the
coronary microvasculature. The endomysium is arranged around each individual
myocyte; it supports and connects them to one another. The perimysium envelopes
the group of myocytes forming bundles of fibers that the epimysium surrounds
(Weber, Sun, Bhattacharya, Ahokas, & Gerling, 2013). The composition of the
ECM is very tightly regulated, involving ongoing synthesis and degradation of
ECM proteins and disturbances in this balance precede structural abnormalities and
impaired function of the heart (Marcin Dobaczewski, Gonzalez-Quesada, &
Frangogiannis, 2010). Collagens are synthesized and secreted by fibroblasts and
myofibroblasts and degraded by matrix metalloproteinases (MMPs) (Lindsey, Iyer,
Jung, DeLeon-Pennell, & Ma, 2016).
Several different pathophysiological conditions can lead to cardiac fibrosis.
The death of cardiomyocytes after MI triggers an inflammatory reaction, removal
of injured cells and cell matrix and replacement of dead myocardium with a fibrotic
scar tissue (Fig. 2). In addition, hypertension, aortic stenosis, hypertrophic
cardiomyopathy and diabetes may induce fibrotic remodeling in the heart (Asbun
& Villarreal, 2006; Ashrafian, McKenna, & Watkins, 2011; Berk, Fujiwara, &
Lehoux, 2007; Dweck, Boon, & Newby, 2012). Normal aging can also be
associated with cardiac fibrosis which increases ventricular stiffness and impairs
diastolic function. Several studies suggest that fibrosis in the aging heart is caused
by reduced matrix degradation rather than by increased collagen synthesis
(reviewed in Biernacka & Frangogiannis, 2011).
Various cell types are involved in fibrotic remodeling of the heart. Depending
on the cause of fibrosis, the relative contribution of different cell types to the
fibrotic process varies. The hallmark of the fibrotic response is the trans-
differentiation of fibroblasts into proliferating myofibroblasts that are able to
secrete large amounts of matrix proteins. The contractile activity of myofibroblasts
25
is increased since they are able to express α-smooth muscle actin (α-SMA). There
are also several cell types, including macrophages, mast cells, lymphocytes,
endothelial cells, and cardiomyocytes that participate indirectly in fibrotic
remodeling by secreting fibrogenic mediators, such as cytokines (tumor necrosis
factor, interleukins (IL)s -1β and IL-6, growth factors (including TGF-β) and
vasoactive peptides such as Ang II and endothelin-1 (ET-1) (for Review, see Kong
et al., 2014).
Two types of cardiac fibrosis exist; reparative fibrosis and reactive interstitial
fibrosis (Rai, Sharma, Agrawal, & Agrawal, 2017). Since adult cardiomyocytes
have a limited proliferation capacity, the dead cells after MI are replaced with a
collagen-rich scar. The healing process after myocardial infarction can be divided
into three overlapping phases: inflammatory, proliferative and maturation phases.
The death of cardiomyocytes triggers an intense inflammatory response with
cytokine and chemokine upregulation and infiltration of activated leukocytes into
the infarcted area. The wound is cleansed of dead cells and ECM debris by
phagocytes and this is followed by a suppression of the inflammatory reaction,
leading to the transition to the proliferative phase. During the proliferative phase,
fibroblasts proliferate and differentiate into myofibroblasts that are capable of
secreting large amounts of ECM proteins, such as collagen. This phenomenon is a
key part of the repair process of the infarcted myocardium. As the scar matures, the
majority of infarct myofibroblasts undergo apoptosis and the ECM proteins become
cross-linked to preserve structural integrity (Marcin Dobaczewski et al., 2010;
Nikolaos G. Frangogiannis, 2014).
A diffuse accumulation of ECM can exist at sites unrelated to a focal injury.
Reactive interstitial fibrosis occurs in animal models of left ventricular pressure
overload in which the initial reactive perivascular and interstitial fibrosis is
followed by cardiomyocyte hypertrophy as an adaptive mechanism to preserve
cardiac function and to decrease ventricular wall tension. Eventually, the
cardiomyocytes seem to undergo apoptosis and necrosis and in those areas,
replacement fibrosis is observed (Rai et al., 2017; Rossi, 1998). Interstitial fibrosis
results in increased mechanical stiffness and thereby in diastolic and systolic
dysfunction and this exposes to the patient to arrhythmias when the electrotonic
connectivity between cardiac myocytes is disrupted. Perivascular fibrosis impairs
the coronary blood flow and myocyte oxygen availability and predisposes to
myocardial ischemia (Brown, Ambler, Mitchell, & Long, 2004).
The origin of the accumulating active myofibroblasts in the fibrotic heart
remains unclear. The most important source might be the activated resident cardiac
26
fibroblasts since numerous proliferating myofibroblasts have been observed in
infarcted hearts (Frangogiannis et al., 1998; Frangogiannis, Michael, & Entman,
2000) and it is believed that these cells sense different pathological stimuli (Ali et
al., 2014; Fredj, Bescond, Louault, & Potreau, 2005; Moore-Morris et al., 2014;
Teekakirikul et al., 2010). Other suggested sources are endothelial cells, epicardial
epithelial cells, pericytes, fibrocytes and hematopoietic bone marrow-derived
progenitor cells (Kong et al., 2014; Travers, Kamal, Robbins, Yutzey, & Blaxall,
2016). However, the contribution of different myofibroblast populations likely
depends on the type of cardiac injury. Unlike in the healing process of the skin
where all myofibroblasts are cleared from the scar, in the heart they can be
identified in the post-MI scar for as long as 17 years after the event (Willems,
Havenith, De Mey, & Daemen, 1994). It has been suggested that the reason for the
maintenance of myofibroblasts in the infarct scar might be to attenuate the
expansion of the scar and prevent the development of HF (van den Borne et al.,
2009).
Fig. 2. Cardiac fibrosis following hypoxic injury involves three overlapping phases:
inflammatory, proliferative, and maturation phases. Inflammatory mediators control
wound healing and removal of death cells which is followed by collagen synthesis and
finally cross-linkage of collagen fibers and scar formation. Time intervals for phases
are suggestive since they vary between species. ECM, extracellular matrix; MMP, matrix
metalloproteinase.
Transforming growth factor β
Transforming growth factor β are pleiotrophic cytokines which perform various
cellular functions, such as the regulation of inflammation, ECM deposition, fibrosis
27
and the control of cell growth, proliferation and differentiation. In mammals, there
exist three structurally similar isoforms, TGF-β1, 2 and 3 that are encoded by three
different genes. TGF-β1 is the most abundantly expressed isoform; this isoform is
found in almost all cell types whereas the other isoforms have more limited
expression patterns in tissues (Bujak & Frangogiannis, 2007; Dobaczewski, Chen,
& Frangogiannis, 2011).
TGF-β is stored in tissues as a latent dimeric complex unable to bind its
receptors. TGF-β is activated by proteolytic cleavage releasing the mature TGF-β
from the complex/inhibitory domain. Several molecules have been described as
TGF-β activators, including proteases, such as plasmin and cathepsin D (Lyons,
Keski-Oja, & Moses, 1988), MMP-2 and MMP-9 (Q. Yu & Stamenkovic, 2000)
and the matricellular protein thrombospondin 1 (Schultz-Cherry, Ribeiro, Gentry,
& Murphy-Ullrich, 1994). In addition, changes in pH can mediate TGF-β activation
(Lyons et al., 1988).
In some animal models of heart failure, upregulated TGF-β levels have been
associated with cardiac hypertrophy and fibrosis. A pressure overload induced by
aortic constriction has been reported to increase TGF-β1 synthesis significantly in
the hypertrophied rat LV (J. M. Li & Brooks, 1997). Ang II signaling correlated to
upregulated TGF-β levels in myocardium after infarction (Sun, Zhang, Zhang, &
Ramires, 1998). TGF-β1 mRNA levels increased also in cultured neonatal rat
ventricular myocytes after treatment with Ang II (Sadoshima & Izumo, 1993) or
norepinephrine (N. Takahashi et al., 1994). Induction of TGF-β1 in the myocardium
could be, at least in part, mediated through Ang II, since treatment of hypertrophied
(Kim et al., 1996) or infarcted rat hearts (Sun et al., 1998; C.-M. Yu, Tipoe, Wing-
Hon Lai, & Lau, 2001) with angiotensin converting enzyme (ACE) inhibitors or
AT1 receptor blockers downregulated TGF-β expression. Moreover, Ang II induced
hypertrophy was abolished in TGF-β1 knockout mice (Schultz Jel et al., 2002).
Elevated cardiac TGF-β1 levels have been detected also in patients with myocardial
hypertrophy due to idiopathic hypertrophic cardiomyopathy (R. K. Li et al., 1997).
In addition to being involved in myocardial remodeling by hypertrophic stimuli,
TGF-β1 is a key molecule in the development of fibrosis. In the healing process of
the infarcted heart, TGF-β regulates the switch from the inflammatory phase to the
proliferative phase and promotes ECM protein synthesis (Bujak & Frangogiannis,
2007). Mice overexpressing TGF-β1 developed a hypertrophic heart accompanied
by interstitial fibrosis in the ventricles when compared with their non-transgenic
controls (Rosenkranz et al., 2002) whereas cardiac-restricted overexpression of
constitutively active mutant human TGF-β1 led to a fibrotic response in the atria
28
but not in the ventricles of the transgenic mice (Nakajima et al., 2000).
Heterozygous TGF-β1 (+/-) deficient mice exhibited attenuated aging-associated
myocardial fibrosis and diastolic dysfunction (Brooks & Conrad, 2000).
TSC-22
The TGF-β stimulated clone 22 (TSC-22) gene sequence was first isolated from
cDNA library of mouse osteoblastic cells treated with TGF-β1 (Shibanuma, Kuroki,
& Nose, 1992). TSC-22 is a highly conserved protein containing a leucine zipper
motif with a molecular mass of 18 kDa. TSC-22 is expressed in various organisms
from Drosophila to humans. The human homologue of the TSC-22 gene was
isolated from a cDNA library extracted from 6 weeks old human embryos (Jay et
al., 1996). At the amino acid level, the human homologue of the TSC-22 is almost
99% identical to the mouse and rat genes. TSC-22 is expressed in several human
adult (including spleen, thymus, prostate, testis, ovary, small intestine, colon, heart,
brain, placenta, lung, liver, skeletal muscle, kidney and pancreas) and fetal
(including brain, lung, liver and kidney) tissues (Jay et al., 1996).
TSC-22 forms homodimers via its leucine zipper domain. It can also
heterodimerize with other transcription factors (Choi et al., 2005; Dobens et al.,
1997; Kester, Blanchetot, Hertog, Van, & Van, 1999; Yan, 2011), such as Smad4
(Choi et al., 2005) and Smad7 (Yan, 2011). TSC-22 has been reported to be
involved in many physiological processes such as the development of Drosophila
melanogaster and mouse (Dobens, Peterson, Treisman, & Raftery, 2000;
Dohrmann, Belaoussoff, & Raftery, 1999; Kester et al., 2000; Treisman, Lai, &
Rubin, 1995), apoptosis (Ohta, Yanagihara, & Nagata, 1997; Yoon et al., 2012) as
well as participating in both cholesterol (Jager et al., 2014) and glucose (Ekim
Üstünel et al., 2016) metabolism. In addition, several studies have focused on the
putative tumor suppressive role of TSC-22 in many cancer cell lines and tumor
tissues (Iida, Anna, Gaskin, Walker, & Devereux, 2007; Kawamata et al., 1998;
Kawamata, Fujimori, & Imai, 2004; Ohta et al., 1997; Shostak et al., 2005; Yoon
et al., 2012; J. Yu et al., 2009). One of the known functions of TSC-22 is to regulate
cellular proliferation via the proto-oncogene, c-MYC. TSC-22 binding inhibits the
suppressive role of c-MYC on cyclin-dependent kinase inhibitors (Zheng, Suzuki,
Nakajo, Nakano, & Kato, 2018).
TSC-22 has been suggested to promote the differentiation of cardiac
myofibroblasts and to contribute to myocardial fibrosis (Yan, 2011). In primary
cardiac fibroblasts isolated from the neonatal rat heart, lentivirus-mediated
29
overexpression of TSC-22 enhanced the TGF-beta-induced expression of several
fibrotic factors e.g. plasminogen activator inhibitor-1 (PAI-1), collagen I and
fibronectin and α-SMA which is a marker for myofibroblast differentiation (Yan,
2011). An upregulation of TSC-22 gene expression in rat heart has been reported
in an experimental model of essential hypertension in spontaneously hypertensive
rats (SHRs) (Rysa, Aro, & Ruskoaho, 2006) as well as after experimental
myocardial infarction (Stanton et al., 2000). The absence of TSC-22 in the heart
has not been studied in detail. TSC-22 knockout mice display a 14% decrease in
the weight of their hearts when compared to wild-type mice (J. Yu et al., 2009).
2.3 Cardiac hypertrophy
The heart responds to diverse physiological and pathological stimuli with
hypertrophic growth (van Berlo et al., 2013). Hypertrophic growth is achieved by
enlarging the existing individual cardiomyocytes since they have only a limited
proliferative capacity. Pregnancy and chronic exercise are two well known
conditions that activate the signalling pathways stimulating myocyte renewal and
reducing cell death resulting in physiological growth with normal cardiac
morphology and function. In physiological hypertrophy, all parts of the ventricle,
chambers, walls and septum enlarge equally and the myocytes gain both width and
length (Maillet, van Berlo, & Molkentin, 2012). Pathological hypertrophy, however,
is initially an adaptive mechanism to normalize wall stress and to maintain cardiac
function but over time, when stress is sustained, these changes become maladaptive
and can progress to HF. Two morphological types of pathological hypertrophy exist.
In concentric hypertrophy, the relative wall and septal thickness increases when the
sarcomeres are added in parallel and the cardiomyocytes mostly increase in width
such that chamber volume can be diminished. Eccentric hypertrophy, in which the
myocytes increase in length rather than width due to the addition of sarcomeres in
series results in an enlargement of the chamber. Relative wall thickness may be
normal, decreased, or increased. Under continuous stress, concentric hypertrophy
can eventually lead to dilated or eccentric hypertrophy. Concentric hypertrophy
often results from hypertension or aortic stenosis whereas eccentric growth is more
common due to volume overload, dilated cardiomyopathy or the situation after
infarction and is characterized with a more advanced cardiac malfunction which
leads to HF (reviewed in Bernardo, Weeks, Pretorius, & McMullen, 2010; Hill &
Olson, 2009; van Berlo et al., 2013).
30
2.3.1 Cardiac hypertrophic stimuli
Cardiac hypertrophic growth is typically initiated either by stretch-sensitive
mechanisms or by certain neuro-endocrine factors and hormones such as Ang II,
ET-1 and TGF-β. These stimuli trigger the induction of complex intracellular
signalling cascades in myocytes that promote hypertrophic gene expression, induce
fibrosis and alter sarcomeric protein organisation (Bernardo et al., 2010; van Berlo
et al., 2013).
Angiotensin II
Angiotensin II is a vasoactive peptide hormone; it is the key effector substance of
the renin-angiotensin aldosterone system which is a major regulatory system of
cardiovascular and renal function. Ang II is produced from angiotensinogen which
is initially cleaved by renin to form angiotensin I (Ang I) which is then activated to
Ang II by ACE (Paul, Poyan Mehr, & Kreutz, 2006). Ang II exerts effects on many
cell types with diverse functions ranging from vasoconstriction, blood pressure
regulation and stimulation of aldosterone release to mediation of growth and
endothelial dysfunction. These cellular events link Ang II to many pathological
cardiovascular processes, such as inflammation, atherosclerosis, thrombosis and
fibrosis that, over time, lead to cardiovascular diseases including MI, stroke and
HF (Mehta & Griendling, 2007).
Several tissues are able to synthesize Ang II locally (Paul et al., 2006). Indeed,
hemodynamic stress can activate a local renin-angiotensin system in the heart
(Lijnen & Petrov, 1999; Yamazaki & Yazaki, 1997). One experiment carried out in
pigs showed that most of the cardiac Ang II peptide was produced from locally
synthesized Ang I (van Kats et al., 1998).
The effects of Ang II in the heart are mediated via Ang II type 1 and Ang II
type 2 receptors (AT1R and AT2R, respectively) that are both G protein-coupled
receptors (GPCRs). Ang II mediates a hypertrophic response in cardiomyocytes
mostly by activating AT1R (Paul et al., 2006). The effects of Ang II mediated via
AT2R on cardiac hypertrophy, however, seem to be complicated since it has been
suggested to have both inducible and inhibitory effects (Lévy, 2004). Transgenic
mice overexpressing AT1R in cardiomyocytes developed cardiomyocyte
hypertrophy and cardiac fibrosis which led to HF without any change in blood
pressure (Paradis, Dali-Youcef, Paradis, Thibault, & Nemer, 2000). This is
evidence that the effects of Ang II occur independently from its actions on blood
31
pressure and furthermore that the local activity of Ang II in cardiomyocytes is
sufficient to induce hypertrophy and remodelling of the heart.
Endothelin-1
Endothelin-1, ET-2 and ET-3 comprise a family of cyclic 21 amino acid peptides
that are encoded by three highly conserved genes. ET-1 is a potent vasoconstrictor
which has autocrine and paracrine regulatory functions in cardiac physiology and
pathology. ET-1 is primarily produced and secreted by endothelin cells and
mediates effects on several cell types in heart. The effects of ET-1 are elicited by
binding to ETA or ETB receptors both of which are GPCRs (Drawnel, Archer, &
Roderick, 2013). Both isoforms are expressed in heart but in cardiomyocytes, the
ETA receptor predominates (B. G. Allen, Phuong, Farhat, & Chevalier, 2003) and
it has higher affinity for ET-1 than the other two family members (Hosoda et al.,
1991).
ET-1 has been shown to have a significant role in cardiomyocyte hypertrophy
and remodelling of the heart. ET-1 transmits a hypertrophic response by activating
different intracellular signalling pathways, such as protein kinase C (PKC) and
mitogen-activated protein kinases (MAPK)s (reviewed in Drawnel et al., 2013). In
cultured cardiomyocytes, ET-1 overexpression induced transcription of various
genes associated with hypertrophy and fetal gene programs (Cullingford et al.,
2008; Ito et al., 1991). The pressure overload induced by aortic banding increased
ET-1 expression levels in rats (Yorikane et al., 1993). Moreover, cardiac-restricted
conditional ET-1 overexpression in transgenic mice caused hypertrophy which
progressed to HF and death (Yang et al., 2004).
2.3.2 Intracellular signalling pathways
Cardiomyocytes undergo cross-talk with the surrounding endothelial cells,
fibroblasts and inflammatory cells as well as integrating signals from ECM, cell
membrane and cellular organelles to translate biomechanical forces into gene
expression. Several factors can initiate hypertrophic stimuli that can activate a
complex network of multiple separate or parallel intracellular signal transduction
pathways that eventually lead to biological responses in cardiomyocytes. These
signalling cascades include protein kinases, such as MAPKs, PKC, and the janus
kinase/signal transducers and activators of transcription (JAK/STAT) pathway and
32
protein phosphatases e.g. the calcineurin/nuclear factor of activated T cells (NFAT)
signalling pathway (Heineke & Molkentin, 2006; Ruwhof & van der Laarse, 2000).
Mitogen-activated protein kinase pathways
Mitogen-activated protein kinases are serine/threonine-specific kinases that relay
extracellular signals that evoke intracellular responses. MAPK pathways are
involved in cell proliferation, differentiation, apoptosis and motility. The activation
of the MAPK signalling cascade is initiated at the cell membrane, where small G
proteins and various protein kinases phosphorylate and activate canonical three-
tiered sequential phosphorylation events. A MAPK kinase kinase activates a
MAPK kinase leading to activation of MAPK through serial phosphorylation. This
canonical activation cascade allows both signal amplification and specificity to
modulate transcription factors that drive context-specific gene expression (Rose,
Force, & Wang, 2010). MAPKs are highly conserved and can been divided into the
three classic MAPK subfamilies i.e. extracellular signal-regulated kinases
(ERK1/2), c-jun N-terminal kinases (JNKs), and p38 kinases. There are some other
atypical MAPKs e.g. ERK3/4, ERK5, ERK7 and Nemo-like kinase. ERK1 and
ERK2 are mainly responsive to stimulation by growth factors, whereas JNKs and
p38 kinases are more specialized transducers of physical, chemical and
physiological stressors, and injury (van Berlo et al., 2013). All three main MAPK
pathways are activated in rodent heart after transverse aortic constriction (TAC)
surgery (Esposito et al., 2001) and in humans suffering from heart failure (Haq et
al., 2001).
The Ras/Raf/MEK1/ERK signalling pathway promotes cardiac hypertrophy.
Transgenic mice with cardiac-specific overexpression of Ras displayed cardiac
hypertrophy (Hunter, Tanaka, Rockman, Ross, & Chien, 1995) and similar results
were observed in transgenic mice overexpressing MEK1 (Bueno et al., 2000).
Cardiac-specific ERK inhibition through the dominant negative form of Raf led to
the situation that the mice became resistant to TAC-induced cardiac hypertrophy
(Harris et al., 2004). ERK1-/- and ERK2+/- mice exhibited a normal cardiac
hypertrophy in response to the pressure overload evoked by TAC (Purcell et al.,
2007).
JNK family members are derived from three genes: JNK1, JNK2 and JNK3.
The activation of JNK is carried out by two MAP kinases, MKK4 and MKK7
(Davis, 1999). The role of JNK pathway in cardiac hypertrophy is somewhat
unclear. JNK1-/-, JNK2-/- and JNK3-/- mice developed cardiac hypertrophy to a
33
similar extent as their wild type counterparts, when subjected to pressure overload
by TAC (Tachibana et al., 2006). However, JNK1-/- mice had reduced LV systolic
function for several weeks after the procedure before returning to normal. These
results suggested that JNK1 was required to maintain cardiac contractility and it
prevented heart failure in the acute phase after pressure overload.
Four p38 MAPKs have been identified: p38α, p38β, p38γ and p38δ, and their
upstream activators are MKK3 and MKK6 (Zarubin & Han, 2005). Overexpression
of MKK3 and MKK6 induced hypertrophic response in cultured cardiomyocytes
(Y. Wang et al., 1998; Zechner, Thuerauf, Hanford, McDonough, & Glembotski,
1997). In vivo, however, activation of p38 was not sufficient to induce hypertrophy.
The cardiac-specific overexpression of MKK3 and MKK6 and the induction of p38
kinase activity did not lead to any significant hypertrophy in transgenic mice when
compared to wild type mice (P. Liao et al., 2001). Instead, the transgenic mice
exhibited increased interstitial fibrosis. The loss of p38 activity in cardiac-specific
p38 DN transgenic mice (S. Zhang et al., 2003) or pressure overload in cardiac-
specific p38 knockout mice had no effect on hypertrophy (Nishida et al., 2004).
The cardiac-specific deletion of p38 resulted in increased apoptosis and fibrosis
(Nishida et al., 2004).
2.3.3 Fetal gene program
The heart responds to the demands posed by overload via an increase in myocyte
mass as well as undergoing changes in gene expression. The first group of genes
activated due to an increased workload is called the immediate-early genes such as
c-fos, c-jun and egr-1; these genes are rapidly and transiently expressed without
any preceding protein synthesis. Many of immediate-early genes encode
transcription factors that are activated by mechanical load or neurohumoral
hypertrophic stimuli (Chien, Knowlton, Zhu, & Chien, 1991; Rysä et al., 2018).
Signaling pathways leading to transcriptional activation of hypertrophic genes are
complex and display significant cross-talk. The key receptors and signaling
cascades involved in hypertrophic growth in adult heart are presented in Fig. 3.
One feature of hypertrophy is that the early response phase is followed by the
activation of a fetal gene program – a set of genes that are normally expressed in
the developing heart but are suppressed in the adult myocardium. ANP and BNP
are synthesized in substantial amounts during embryonic development but their
levels in the healthy adult ventricle are low (Gardner, 2003). Re-expression of ANP
and BNP is induced by a wide variety of load stimuli in several species (Hama et
34
al., 1995; Kerkelä et al., 2015; Ogawa et al., 1991; T. Takahashi, Allen, & Izumo,
1992) and elevated natriuretic peptide plasma levels are used as clinical indicators
of cardiac hypertrophy (Kerkelä et al., 2015). Since natriuretic peptides have
natriuretic, diuretic and vasodilatory effects, their overall function may be to protect
the myocardium by inhibiting the hypertrophic response (Barry et al., 2008).
Other characteristics of the fetal gene program appear to be that the expression
of several sarcomeric proteins becomes switched to fetal isoforms from their adult
counterparts. In the developing mammal heart, β-MHC is the abundant isoform. In
rats and mice, the α-MHC predominates after birth as well as in the mature heart
but in larger mammals, such as humans, the β-MHC isoform dominates also in the
adult ventricle. However, due to the elevated work load, the ratio of the cardiac
MHC isoforms changes in all species. The β-MHC has lower ATPase activity
which leads to a slower and more economical contractility function in the larger
cardiac myocytes (Bernardo et al., 2010; Nadal-Ginard & Mahdavi, 1989). In
addition, the switch from cardiac α-actin to skeletal α-actin, which is the fetal
isoform, has been associated with better contractility in a loaded heart (Hewett,
Grupp, Grupp, & Robbins, 1994; Schwartz et al., 1986).
35
Fig. 3. A simplified diagram of the key signalling pathways involved in cardiac
hypertrophy. Hypertrophic growth of cardiomyocytes is triggered by neurohumoral
activation and biomechanical stress produced by cardiac overload. Ang II, angiotensin
II; ANP, atrial natriuretic peptide; β-MHC, β-myosin heavy chain; BNP, B-type natriuretic
peptide; CAMKII, calcium-calmodulin-dependent kinase; GATA4, GATA binding protein
4; ET-1, endothelin-1; gp130, glycoprotein 130; GPRC, G-protein coupled receptor;
HDACs, histone deacetylases; IP3, inositol triphosphate; JAK, Janus kinase; MAPKs,
mitogen-activated protein kinases; MAPKK, MAPK kinase; MAPKKK, MAPK kinase
kinase; MEF2, myocyte enhancer factor 2; NFAT, nuclear factor of activated T cells; PLC,
phospholipase C; SRF, serum response factor; STAT, signal transducer and activator of
transcription. Modified from Bernardo et al., 2010; Shah & Mann, 2011; Tham, Bernardo,
Ooi, Weeks, & McMullen, 2015.
2.3.4 Actin proteins
The contraction unit in cardiac muscle is composed of two important filaments,
actin and myosin. Actin is essential for several basic functions in organisms,
including cell motility, maintaining cell shape, endo- and exocytosis, cell division
36
and muscle contraction (Perrin & Ervasti, 2010; Tondeleir, Vandamme,
Vandekerckhove, Ampe, & Lambrechts, 2009). Actin is highly conserved between
species and is expressed in all eukaryotic cells (Vandekerckhove & Weber, 1978).
In mammals, there are six different actin isoforms: tissue-restricted skeletal α-actin,
cardiac α-actin, α-SMA and γ-SMA, and ubiquitously expressed cytoplasmic β-
cytoplasmic actin and γ-cytoplasmic actin. The isoforms differ only by few amino
acids but they seem to have unique expression patterns and specific cellular
functions in the tissues in which they predominate (Vandekerckhove & Weber,
1978).
Along with myosin, cardiac α-actin and skeletal α-actin are important
components of the contraction unit in striated heart and skeletal muscle. Both types
exist in cardiac muscle but their expression patterns differ spatially and temporally.
During cardiac development, skeletal α-actin predominates but after birth, the adult
isoform, cardiac α-actin, is the main thin filament component. In normal adult
rodent heart, the expression levels of skeletal α-actin are low but during the
remodeling process in hypertrophied and failing hearts, skeletal α-actin expression
is re-induced (Omura et al., 2000; Schwartz et al., 1986). The switch to the fetal
actin isoform can be induced both in vivo due to pressure load or myocardial
infarction (Nadal-Ginard & Mahdavi, 1989; Omura et al., 2000; Schwartz et al.,
1986) and in vitro in cultured cardiomyocytes by mechanical load (Komuro et al.,
1991; Sadoshima, Jahn, Takahashi, Kulik, & Izumo, 1992).
All actin isoforms seem to have specialized functions since knockout mouse
models of actin isoforms have distinct phenotypes. Most of the cardiac α-actin null
mice die prenatally, and those that survive until birth, die within two 2 weeks
(Kumar et al., 1997). Both the homozygous and heterozygous cardiac α-actin mice
expressed increased levels of skeletal α-actin and α-SMA in their hearts but this
was insufficient to restore the deficient myofibrillar function in these knockout
mice. In addition, cardiac α-actin knockout mice were able to reach adulthood when
γ-SMA was overexpressed under the control of cardiac α-myosin heavy chain
promoter. However, the hearts of these transgenic mice are hypodynamic, enlarged
and hypertrophic (Kumar et al., 1997). Skeletal α-actin deficient mice appear
healthy at birth but die within 9 days after birth with reduced muscle strength and
growth deficits (Crawford et al., 2002). However, the transgenic expression of
cardiac α-actin sufficiently rescued the lethality and prevented the reduction in
muscle function associated with the loss of skeletal α-actin (Nowak et al., 2009).
In BALB/c mice, a perturbation to the cardiac α-actin locus resulted in hearts
that contained up to 50 % of the skeletal α-actin. The hearts of these mice had better
37
contractility (Garner, Minty, Alonso, Barton, & Buckingham, 1986; Hewett et al.,
1994). Normal hearts of large mammals such as humans expressed higher levels of
skeletal α-actin mRNA than small mammals such as rodents (Boheler et al., 1991);
this has been postulated to account for their better contractility due to the abundant
amounts of skeletal α-actin (Chaponnier & Gabbiani, 2004; Yin, Ren, & Guo, 2015).
Overall, these observations from mouse models emphasize the compensatory
expression of muscle actin isoforms and the importance of the balance in actin
levels in order to meet the requirements of cell specific function.
There are a few mutations in cardiac α-actin that have been associated with
DCM and HCM (Arad et al., 2005; Mogensen et al., 2004; Mogensen et al., 1999;
T M Olson, Michels, Thibodeau, Tai, & Keating, 1998; T M Olson et al., 2000; Van
Driest et al., 2003). It has been suggested that in patients with DCM, mutations in
cardiac α-actin affect the force transmission from the sarcomere to the surrounding
syncytium (Mogensen et al., 1999). However, mutations associated with HCM
have been proposed to affect sarcomere contraction due to an impaired formation
of actin filaments or due to interference with the actin-myosin interaction
(Mogensen et al., 2004; T M Olson et al., 2000).
2.3.5 Phosphatase and actin regulatory proteins
The Phactr family of phosphatase and actin regulatory proteins comprises four
members: Phactr1, Phactr2, Phactr3/Scaponin and Phactr4. They act as modulators
of protein phosphatase 1 (PP1) and bind to actin. In rats, Phactrs are expressed
widely in the central nervous system with lower expression levels being found in
lung, heart, kidney and testis (P. B. Allen, Greenfield, Svenningsson, Haspeslagh,
& Greengard, 2004). Depending on the cell type and cell cycle, different subcellular
localization patterns of Phactrs have been reported from nucleus to cytosol and
plasma membrane (P. B. Allen et al., 2004; Huet et al., 2013; Itoh, Uchiyama,
Taniguchi, & Sagara, 2014; Sagara et al., 2003; Sagara, Arata, & Taniguchi, 2009;
Y. Zhang, Kim, & Niswander, 2012).
Phactr proteins are conserved, 75 kDa in size with each Phactr protein
containing one N-terminal RPEL motif and a C-terminal triple RPEL repeat
followed by the PP1-binding domain. Phactrs have been implicated in several
biological processes including the regulation of actin cytoskeleton dynamics (Fils-
Aime et al., 2013; Wiezlak et al., 2012), the modulation of cell motility and
migration (Sagara et al., 2009), axon elongation (Farghaian et al., 2011) and
angiogenesis (Allain et al., 2012; Jarray et al., 2011).
38
Phactrs have been linked to some human diseases such as coronary artery
disease and myocardial infarction, cancers and Parkinson’s disease (Bankovic et al.,
2010; Consortium, 2009; Solimini et al., 2013; Wider et al., 2009).
Phosphatase and actin regulator 1
The PHACTR1 locus has been associated with CAD and MI in several
genome-wide association studies (GWAS) (Consortium, 2009; Hager et al., 2012;
Lu et al., 2012; Matsuoka et al., 2015; Odonnell et al., 2011; Paquette, Dufour, &
Baass, 2018; Patel et al., 2012; Jessica van Setten et al., 2013). PHACTR1 has also
been linked to migraine without aura (Freilinger et al., 2012), cervical artery
dissection (Debette et al., 2015), and fibromuscular dysplasia (Kiando et al., 2016)
in GWAS (Allain et al., 2012). Phactr1 has been reported to modulate vascular
calcification in murine embryonic stem cell-derived smooth muscle cells
(Aherrahrou, Aherrahrou, Schunkert, & Erdmann, 2017). In a DNA microarray
study using cultured rat cardiomyocytes, Phactr1 was shown to be activated by
mechanical stretch (Rysä et al., 2018).
In human tissues, PHACTR1 has been detected in the brain and aorta as well
as in normal and infarcted heart (Beaudoin et al., 2015). PHACTR1 controls tube
formation and cell survival in Human Umbilical Vascular Endothelial Cells
(HUVECs) since PHACTR1 depletion by siRNA induced apoptosis (Jarray et al.,
2011). The same research group found also that down-regulation of PHACTR1
disrupted the control of actin polymerization and prevented the depolymerization
in HUVECs.
In human melanoma cells, PHACTR1 seems to be required for actomyosin
assembly and the invasive behavior of these malignant cells (Wiezlak et al., 2012).
Binding to PP1 was inhibited by the interaction of G-actin with the C-terminal
RPEL repeat of PHACTR1 (Wiezlak et al., 2012). In human breast cancer cells, a
PHACTR1 knockdown impaired actin dynamics (polymerization and
depolymerization) which is needed for cell motility and migration (Fils-Aime et al.,
2013). PHACTR1 was discovered to be a negatively regulated downstream target
of a potential tumor suppressor miRNA-584 the levels of which were down-
regulated by TGF-β during cell migration of breast cancer cells. Thus, increased
expression of PHACTR1 seems to be required for TGF-β-induced cell migration
(Fils-Aime et al., 2013). These reports highlight the importance of PHACTR1 in
actin related cellular processes.
39
2.3.6 Transcription factors in cardiac hypertrophy
Several transcription factors that are active during the development of the heart
reappear in a stressed adult heart as a part of the fetal gene program. The cardiac-
expressed transcription factors that are involved in cardiac hypertrophy, such as
GATA-4, Nkx2.5, Smads, serum response factor (SRF), myocardin-related
transcription factors (MRTFs) and myocyte enhancer factor-2 (MEF-2) have been
reviewed by Kohli et al. (Kohli, Ahuja, & Rani, 2011) and Oka et al. (Oka, Xu, &
Molkentin, 2007). Here the focus will be placed on SRF and the MRTFs that act as
SRF co-factors and have a regulatory role in gene expression of actin proteins.
Serum response factor
Serum response factor (SRF) belongs to a family of proteins that contain a MADS
(Mcm1 and Arg80 in yeast, Agamous and Deficient in plants, and SRF in animals)
box domain and which act as transcription factors. SRF binds to serum response
elements, more specifically to the CArG box DNA consensus CC(A/T)6GG which
is found in the promoters of SRF target genes (E. N. Olson & Nordheim, 2010).
SRF is ubiquitously expressed but through recruitment of many cell-type specific
cofactors, it can adopt specialized roles in different cellular environments
(Mikhailov & Torrado, 2012). SRF is important in cardiac development and growth
when it acts as a pivotal transcriptional regulator of the numerous genes necessary
for cardiac function and contraction, such as immediate early transcription factors
and actin proteins that are re-activated in the adult heart as part of the cardiac
hypertrophic response (Parmacek, 2007).
The development of SRF knockout mouse embryos ceased before mesoderm
formation and the embryos displayed reduced expression levels of both the early
response genes c-fos and Egr-1 and α-actin, i.e. well-known SRF target genes
(Arsenian, Weinhold, Oelgeschläger, Rüther, & Nordheim, 1998). Similar results
were obtained by cardiac-specific ablation of SRF which led to failed cardiogenesis
and down-regulation of SRF-targets α-actin and SM22α (Niu et al., 2005). SRF
deficient cardiomyocytes exhibited impaired Z-disc and stress fiber formation with
mislocalization and reduced expression of sarcomeric proteins, evident signs of a
defective contractile apparatus structure and function (Balza & Misra, 2006).
The regulatory role of SRF is not restricted to development as revealed in
studies with adult transgenic mice. Transgenic mice with cardiac-specific SRF
overexpression suffered from cardiac hypertrophy with fibrosis (X. Zhang et al.,
40
2001). Cardiac specific Cre-mediated loss of SRF in adult mice led to dilated
cardiomyopathy with impaired contractility and LV function that rapidly
progressed to heart failure (Parlakian et al., 2005). Gene expression of cardiac
alpha-actin was markedly downregulated and changes in the expression of the
genes involved in calcium-handling and energy flux were also detected. Since both
the cardiac-specific SRF overexpression and deletion have been associated with a
cardiomyopathic state, the activation and function of SRF has to be strictly
regulated.
Myocardin-related transcription factors
Myocardin-related transcription factors (MRTFs), including myocardin, MRTF-
A/MKL1/MAL and MRTF-B/MKL2, comprise a family of proteins that function
as powerful coactivators of SRF. MRTFs bind to SRF and synergistically activate
the transcription of the genes involved in cytoskeletal organization and muscle cell
differentiation and function (Parmacek, 2007). Myocardin is expressed primarily
in cardiac and smooth muscle cells whereas MRTF-A and MRTF-B display more
widespread expression patterns (D.-Z. Wang et al., 2002). MRTFs exhibit strong
homology and in the N-terminus they have RPEL domains that in MRTF-A and
MRTF-B are able to bind monomeric G-actin which via Rho signaling regulate
MRTF-mediated transcription of the SRF-dependent genes encoding contractile
and cytoskeletal proteins (Parmacek, 2007).
Myocardin is necessary for smooth muscle cell differentiation since myocardin
deficient mice embryos die early and fail to develop vascular smooth muscle cells
while cardiogenesis occurs normally (S. Li, Wang, Wang, Richardson, & Olson,
2003). Cardio-restricted ablation of myocardin in adult mice leads to DCM with
disruptions in sarcomeric organization, increased cardiomyocyte apoptosis and
depressed systolic function (Huang et al., 2009). Different hypertrophic signals
such as phenylephrine, ET-1 (Xing et al., 2006), aldosterone and isoproterenol (K.
Wang, Long, Zhou, & Li, 2010) have induced myocardin expression in neonatal
cardiomyocytes; in hypoxia, the elevated expression of myocardin is apparently
mediated via Ang II and the ERK pathway (Chiu, Wang, Chung, & Shyu, 2010).
Overexpression of myocardin induced hypertrophy and expression of fetal genes
(Xing et al., 2006).
MRTF-A null mice are viable and show no obvious organ abnormalities.
However, knockout females are unable to productively nurse their offspring due a
failure in mammary myoepithelial cell differentiation, evidence that MRTF-A
41
could be a regulator of myoepithelial cell development (S. Li, Chang, Qi,
Richardson, & Olson, 2006; Sun et al., 2006). Furthermore, Sun et al. have shown
that 35% of MRTF-A-/- mouse embryos suffered lethal dilatation of cardiac
chambers although the rest of the embryos exhibited no obvious abnormalities (Sun
et al., 2006). Based on these studies, it seems that MRTF-A has an unclear role in
cardiovascular development. Although homozygous MRTF-A null adult mice have
no obvious cardiac deficiencies under basal conditions, they display an abnormal
adaptation to cardiac overload.
Adult mice lacking the MRTF-A gene show an attenuated hypertrophic
response both to the acute (1h) and chronic pressure (3 weeks) overload induced
by thoracic aortic banding. The expression levels of BNP, skeletal α-actin and
smooth muscle α-actin genes were significantly up-regulated in wild-type mice but
the increases were significantly attenuated in MRTF-A null mice. The expression
of BNP and skeletal α-actin was also weaker in MRTF-A-/- mice than in their wild-
type counterparts when the pressure overload was induced by chronic Ang II
treatment (Kuwahara et al., 2010).
In cultured neonatal rat cardiomyocytes, the overexpression of MRTF-A
induced hypertrophic growth and the expression of cardiac hypertrophy marker
genes. In addition, the expression of MRTF-A was up-regulated by hypertrophic
signals, whereas inhibition of endogenous MRTF-A expression by dominant-
negative mutant or siRNA reduced the abilities of phenylephrine, Ang II and TGF-
β toinduce hypertrophy in cultured cardiomyocytes (X.-H. Liao et al., 2011).
In contrast to MRTF-A knockout mice, MRTF-B knockout embryos have a
lethal phenotype and cardiovascular defects, including a thin-walled myocardium,
ventricular septal defects, an abnormal patterning of the branchial arch arteries and
truncus arteriosus (J. Li et al., 2005; Oh, Richardson, & Olson, 2005; Wei, Che, &
Chen, 2007). However, mice with a cardiomyocyte-specific deletion of MRTF-B
are viable and display a normal phenotype at least until the age of one year
(Mokalled et al., 2015). The group of Mokalled bred these mice with constitutive
MRTF-A knockout mice to generate mice lacking both MRTF-A and MRTF-B in
the heart. Most of these double knockout mice died within 2 weeks after birth and
the rest succumbed before the age of 13 weeks. Neonatal MRTF-A/B null mice had
defects in sarcomeric organization and function whereas those few mice reaching
early adulthood had reduced cardiac contractility and adult onset heart failure.
42
2.4 Identifying genetic susceptibility and molecular markers for
heart failure
Human genetics provides a powerful and unbiased tool to discover causal
mediators of pathophysiology of cardiac diseases. The Human Genome Project and
the development of economical and reliable DNA technology arrays applicable to
high-throughput and large-scale data generation have enabled genome wide
analyses. In addition, the availability of large population data with hundreds or
thousands of subjects is needed to provide sufficient statistical power to detect true
associations of modest genetic effects (Manolio, 2010).
2.4.1 Genome-wide association studies
Genome-wide association studies (GWAS) involve genotyping a large set of
genetic variants and comparison of allele distributions between cases with a disease
and controls without the disease of interest (J. G. Smith & Newton-Cheh, 2015).
Unlike conventional methods that concentrate on one or a few genes or genetic
regions, the GWAS investigate the whole genome. Scanning of the genome can be
used in several study designs, such as cohort studies, case-control studies and
clinical trials (Manolio, 2010). The most common forms of DNA variation are
single nucleotide polymorphisms (SNPs) which are defined as variants with an over
5% prevalence in the population. For comparison, single base mutations occur with
a frequency of < 1% whereas variants observed at an intermediate frequency >1%
but <5% are considered rare variants (Dubé & Hegele, 2013).
GWAS usually focus on the associations between SNPs and traits like major
diseases of question. GWAS can also be carried out from the aspect of phenotype-
first. Subjects known to differ from a particular quantitative trait, such as blood
pressure or ejection fraction are classified initially by their clinical manifestation
and this is followed by genomic association studies. In GWAS, the frequency or
intensity of a biallelic genetic variant between case and control subjects is
compared in SNP arrays, and a allele that is more frequently observed in subjects
with the disease is considered to be associated with the disease and is defined as
the risk allele (Dubé & Hegele, 2013). The associations need to be tested with a
large number of statistical analyses and require extreme levels of statistical
significance (Zeller, Blankenberg, & Diemert, 2012). The position of the variant
in the genome need not necessarily be located in the coding regions, in fact the vast
majority (>80 %) of SNP-trait associations reside in non-coding regions (Hindorff
43
et al., 2009). Genetic variants identified to a certain locus of human genome and
associated with a disease in GWAS cannot, on their own, specify which genes are
causal. They might rather be in linkage disequilibrium with a causal variant located
nearby on the same chromosome (Kessler, Vilne, & Schunkert, 2016) and for that
reason, additional investigations are needed to identify exact mechanisms.
GWAS are a powerful technique for identifying genetic variants and relating
these to complex disorders. However, GWAS also have their own limitations and
challenges. GWAS require large sample sizes in order that they can fulfil the strict
thresholds of statistical significance (P < 5×10-8) and they have the potential to
produce false-positive results and genotyping errors. They are insensitive to rare
variants and structural variants, and the selection of control and case needs to be
performed carefully to avoid biases (Pearson & Manolio, 2008). Nonetheless,
GWAS can help to detect genetic loci for multifactorial diseases. However, since
the majority of the associated loci are found in non-coding regions, these
associations lack any link to specific genes and to pathophysiological mechanisms
through which these variants predispose to disease and thus additional molecular
studies are needed to identify the variants causing the disease of interest (Manolio,
2010; Zeller et al., 2012).
Genome-wide association studies in heart failure
To date, genome-wide association studies have identified 184 SNPs associated
with HF, corresponding to two studies. Table 1 represents the 20 GWAS SNPs with
the strongest (smallest p-value) association with heart failure (M. J. Li et al., 2012).
Since non-congenital HF is a multifactorial syndrome which can develop slowly as
a result of conditions such as CAD and hypertension, most GWAS in HF have been
designed to investigate those SNPs associated with these risk factors. Blood
pressure and dyslipidemia are important quantitative traits that predispose to HF. A
multi-stage meta-analysis of 200 000 individuals of European ancestry has
identified a total of 16 loci regulating blood pressure (International Consortium for
Blood Pressure Genome-Wide Association Studies et al., 2011). In a similar
population sample of over 100 000 participants, 95 common variants associated
with dyslipidemia were screened and also found to correlate with CAD (Teslovich
et al., 2010). Interestingly, some studies have found new loci associated with CAD
without affecting traditional risk factors (Peden et al., 2011; Schunkert et al., 2011).
A couple of new SNPs associated with early-onset MI have also been identified in
a multi-staged meta-analysis (Consortium, 2009).
44
The meta-analysis of cohort studies examined nearly 21000 European-ancestry
individuals and almost 3000 African-ancestry individuals who were followed-up
for incident heart failure events. One locus from both ancestry groups was
identified, rs10519210 (nearest gene Ubiquitin carboxyl-terminal hydrolase 3) in
European-ancestry participants and rs11172782 (nearest gene Leucine-rich repeats
and immunoglobulin-like domains protein 3) among African-ancestry participants
(N. L. Smith et al., 2010). Another meta-analysis of the same cohort identified one
loci, rs12638540 (in an intron of CKLF-like MARVEL transmembrane domain
containing 7) that was significantly associated with all-cause mortality in
individuals of European-ancestry with HF (Morrison et al., 2010). However, these
findings will need to be replicated. Another case control study included almost
1600 Caucasian patients with heart failure and nearly 600 controls (Cappola et al.,
2010). In this study, about 50000 SNPs in 2000 genes linked to cardiovascular
disorders were analysed. Of these, two SNPs, rs1739843 (heat shock protein family,
member 7) and rs6787362 (FERM domain-containing protein 4B), were associated
with advanced heart failure.
45
Table 2. The 20 most significant loci for heart failure loaded from GWAS database.
SNP id pubmedid/
dbGaP id
Chromo-
some
p-value Gene Function
rs12638540 20400778 3 0.0000003 CMTM7 B-1a B cell differentiation
rs729201 pha002884 16 0.000000785 CDH15 calcium ion binding
rs2125623 20400778 15 0.000001 OTUD7A DNA binding
rs6868223 20400778 5 0.000002 ADAMTS12 metalloendopeptidase activity
rs2241032 pha002884 16 0.00000353 GAS8 epithelial cilium movement
rs2731968 pha002884 5 0.00000376 EGFLAM calcium ion binding
rs7687921 20400778 4 0.000004 GPM6A neuron migration
rs11880198 20445134 19 0.000006 GNA15 G-protein coupled receptor binding
rs7120489 20400778 11 0.000007 PARVA sprouting angiogenesis
rs17121271 pha002885 13 0.00000709 TUBGCP3 structural molecule activity
rs2964519 pha002884 5 0.00000723 RANBP17 GTP binding
rs3805455 pha002884 5 0.0000076 GABRP extracellular ligand-gated ion channel
activity
rs17159640 20400778 7 0.000009 IFRD1 nucleus
rs11582563 pha002885 1 0.0000128 TRIM33 negative regulation of transcription
by RNA polymerase II
rs1565862 pha002885 12 0.0000132 CPM carboxypeptidase activity
rs885479 pha002884 16 0.0000142 MC1R melanocortin receptor activity
rs1372173 pha002885 8 0.00003 CNGB3 photoreceptor outer segment
rs10506584 pha002884 12 0.0000303 CNOT2 negative regulation of transcription
by RNA polymerase II
rs2035645 pha002884 15 0.0000342 ST8SIA2 Golgi membrane
rs10483611 pha002885 14 0.0000348 GPR137C integral component of membrane
Function inferred from Gene Ontology database top hit.
2.4.2 Genome-wide gene expression profiling studies
Advances in the genome projects and in computational biology led to the
development of high-throughput methods for genome-wide gene expression
analyses i.e. transcriptomics. At first, DNA microarrays containing predetermined
sequences were widely used (Trevino, Falciani, & Barrera-Saldaña, 2007). In DNA
microarrays, a collection of DNA probes are attached to the surface as spots.
Purified nucleic acid from the cells or tissue to be studied is labelled with a
fluorophore and hybridized to the array. The image is scanned and the intensity of
the signal is analysed to determine the relative abundance of bound molecules
(Goodwin, McPherson, & McCombie, 2016). Currently, whole next-generation
sequencing (NGS) technologies (also known as high-throughput sequencing) that
46
make it possible to examine the whole sequence, are increasingly being used in
biomedical research (Goodwin et al., 2016; Mardis, 2013). In humans,
transcriptomic studies e.g. in heart failure (Margulies et al. 2005) and different
cardiomyopathies (Hannenhalli et al., 2006) have been performed, and gene
expression profiles have been related in different pathological conditions e.g. in the
prognosis of heart failure (Heidecker et al., 2008) and with respect to the
atherosclerosis burden of coronary and carotid arteries (Ma & Liew, 2003; Patino
et al., 2005). In animal studies, transcriptomics has been widely utilized to screen
gene expression levels in various experimental models of cardiovascular diseases
(Harpster et al., 2006; Rysa et al., 2005). At the level of individual cardiac cells,
transcriptomic profiles of cardiomyocytes, fibroblasts, leukocytes, and endothelial
cells from infarcted and non-infarcted neonatal and adult mouse hearts (Quaife-
Ryan et al., 2017) as well as sex-specific transcriptomic profiles of adult rat
ventricular myocytes have been characterized (Trexler, Odell, Jeong, Dowell, &
Leinwand, 2017). Ultimately, the integration of genotyping and expression data can
be used to reveal the cardiovascular disease-associated genes. Figure 4 represents
epigenetic regulatory factors, genomic variants and cellular modifications leading
to a certain phenotype as well as the different “omic” technologies used to explore
the actions and relationships between these molecules.
47
Fig. 4. Schematic presentation of the relationship between different “-ome/-omics”
components, epigenetic regulatory factors, gene transcription, post-translational
modification, protein localization and function, contributing to different functions in
cells and tissues, and eventually leading to certain phenotype. The genome integrates
intrinsic and environmental signals. Kinases and phosphatases modulate the cellular
activities of the proteins in the responses to external stimuli. The environment can
interact directly with the genome to cause reversible epigenetic changes and thus affect
gene expression and silencing. “Omics”-based approaches provide opportunities to
discover biomarkers for diseases. Modified from Pasipoularides, 2017.
48
49
3 Aims of the research
The aim of the study was to characterize the role of novel load-inducible genes in
cardiac hypertrophy and LV remodeling in different experimental models of cardiac
hypertrophy and failure. In addition, an Rd3l knockout mouse line was generated
to investigate the function of Rd3l in the overloaded heart. Specifically the
objectives were:
1. To examine the expression of Phactr1 in LV remodeling post-MI and to
investigate the effects of adenovirus-mediated Phactr1 overexpression in vivo
on cardiac function and in vitro in cultured cardiomyocytes.
2. To study the cardiac TSC-22 expression in vivo during different experimental
models of cardiac load.
3. To determine Rd3l expression in the heart during cardiac load and to generate
an Rd3l knockout mouse line to clarify the function of Rd3l in the animals’
response to the pressure overload in the heart.
50
51
4 Materials and methods
The experimental models and the average number of animals used in the models
are summarized in Table 2. The methods used in original publications are listed in
Table 3. Detailed descriptions with references can be found in the original
publications I-III.
Table 3. Summary of the experimental models and methods.
Original publication Experimental models Average number of animals
used/model
I Adenovirus-mediated gene transfer in vivo and
in vitro
150
Myocardial infarction 60
Cell culture
II Adenovirus-mediated gene transfer in vivo and
in vitro
26
Myocardial infarction 42
Pressure overload (Arginine8-vasopressin and
Ang II)
90
Losartan infusion 26
Cell culture
III Pressure overload (Ang II) 56
Myocardial infarction 42
Establishment of a knockout mouse line
Pressure overload (TAC) 40
Animals used in the establishment of a knockout mouse line and the neonatal pups used for in vitro cell
culture experiments are excluded
52
Table 4. Summary of the methods used in each publication.
Original publication Method
I Production of adenoviral vectors
Antibody production
RNA isolation and real-time quantitative RT-PCR
Protein extraction
Western blot
EMSA
Echocardiography
Histological analysis
Statistical analysis
II Antibody production
RNA isolation, Northern blot and real-time quantitative RT-PCR
Protein extraction
Western blot
Echocardiography
Histological analysis
Statistical analysis
III DNA cloning
Antibody production
Southern blot
RNA isolation, Northern blot and real-time quantitative RT-PCR
Echocardiography
Histological analysis
Statistical analysis
53
5 Results and discussion
The most relevant findings from the original articles are presented and discussed
here. The original publications are referred to by the Roman numerals I-III and
figures with the corresponding numbers as in the original articles.
5.1 Phactr1 expression is rapidly reduced in experimental MI (I)
Although PHACTR1 has been associated with MI and CAD in GWAS (Consortium,
2009; Hager et al., 2012; Lu et al., 2012; Matsuoka et al., 2015; Odonnell et al.,
2011; Patel et al., 2012; van Setten et al., 2013), the function of PHACTR1 in the
heart is unknown. First, the effect of post-infarction myocardial remodeling on
Phactr1 expression in adult rats in a model of acute MI induced by ligation of left
anterior descending coronary artery was investigated. Rapid and significant
reductions both in Phactr1 mRNA and protein levels (0.4-fold and 0.9-fold,
respectively) were observed already at 1 day in response to MI (I, Fig 1A-B). The
expression levels returned to basal levels in two weeks. This suggests that Phactr1
could have a role in the early remodeling process after infarction.
Stretching of cardiomyocytes occurs in the remodeling heart after acute MI
(Force, Michael, Kilter, & Haq, 2002). Mechanical stretch activates intracellular
signalling pathways, including the p38 MAPK pathway and leads to changes in
gene expression (Rohini, Agrawal, Koyani, & Singh, 2010; Rose et al., 2010).
Phactr1 mRNA levels were downregulated both in stretched cardiomyocytes and
after p38 overexpression in cultured neonatal rat ventricular myocytes (NRVMs) (I,
Fig 1C-D). This suggests that cardiac overload post-infarction down-regulates
Phactr1 expression in the heart via the p38 MAPK pathway triggered by direct
mechanical myocyte stretch. However, to clarify the precise function of
endogenous p38 in regulation of Phactr1, p38 MAPK inhibition experiments will
be needed.
5.2 Phactr1 regulates skeletal α-actin to cardiac α-actin switch (I)
An adenoviral gene transfer protocol was used to examine the direct myocardial
effects of Phactr1 in the normal adult rat LV and in hearts during the post-infarction
remodelling process. Significantly increased and sustained Phactr1 mRNA and
protein levels were detected for up to 2 weeks when compared to control animals
54
receiving virus expressing LacZ also at a virus dose of 5×108 infectious units (I,
Fig 2 C-D, 7A-B).
One feature of the remodelling process of the stressed heart is the appearance
of the fetal gene program (Burchfield et al., 2013; Taegtmeyer et al., 2010). The
early response includes transcription of c-fos, c-jun and early growth response -1
(EGR-1), followed by reprogramming of cardiac gene expression including up-
regulation of natriuretic peptides and a switch to fetal isoforms of contractile
proteins such as cardiac α-actin being substituted by skeletal α-actin (Frey, Katus,
Olson, & Hill, 2004; Izumo, Nadal-Ginard, & Mahdavi, 1988; Taegtmeyer et al.,
2010). Normally, only cardiac α-actin is expressed in the adult rat heart but the
expression of the fetal form, skeletal α-actin, is reactivated in the pathologically
stressed heart (Nadal-Ginard & Mahdavi, 1989). Mechanical loading induces the
expression of skeletal α-actin also in vitro in cultured cardiomyocytes (Komuro et
al., 1991; Sadoshima et al., 1992). Since Phactrs are a family of actin regulatory
proteins, the effect of Phactr1 overexpression on contractility proteins was studied.
The key finding emerging from this study is that Phactr1 overexpression changed
the skeletal α-actin to cardiac α-actin ratio both in vivo and in vitro. Phactr1
overexpression significantly elevated the skeletal α-actin to cardiac α-actin ratio
(1.5-fold, P<0.05) 3 days after Phactr1 gene delivery but the ratio was reduced (0.6-
fold, P<0.05) at 2 weeks in normal adult rat hearts (I Fig 3A and E). A similar effect
was seen in infarcted rat hearts where the skeletal to cardiac α-actin ratio was 50%
lower at 2 weeks after the MI (P<0.05) (Fig 7C). In agreement with in vivo studies
at 3 days, the skeletal α-actin to cardiac α-actin ratio significantly increased (1.8-
fold, P<0.001) in response to adenovirus-mediated Phactr1 overexpression for 48
hours in cultured NRVMs (I, Fig 9B). Phactr1 mRNA expression levels post-MI
and the effect of Phactr1overexpression on the skeletal α-actin to cardiac α-actin
ratio at 2 weeks in normal adult rat hearts and at 2 weeks after MI are shown in
Figure 5. The extractions were done from the whole LV anterior wall in order to
investigate mRNA and protein levels in the infarcted hearts. More detailed data of
the gene expression could have been gathered if the infarct region and the remote
non-infarcted area would have been separated, since the gene expression levels may
vary between these distinct areas.
55
Fig. 5. A) Phactr1 mRNA levels from the LV tissue samples 1 day, 2 weeks and 4 weeks
after MI. B) The effect of Phactr1 gene transfer on the skeletal α-actin (skα-A) to cardiac
α-actin (caα-A) ratio 2 weeks after Phactr1 gene transfer and C) 2 weeks after Phactr1
gene delivery and MI. mRNA levels are measured by RT-PCR. The results are expressed
as mean ± SEM. *P<0.05, **P<0.01 versus sham, LacZ or MI+LacZ (Student’s t-test).
56
5.3 SRF DNA binding activity is enhanced due to Phactr1
overexpression in vitro (I)
Increased DNA binding activity of SRF (1.7-fold, P<0.05) was observed due to
Phactr1 overexpression in cultured NRVMs (I, Fig 9D). SRF is a transcription
factor that binds to serum response elements (SREs) and is an important regulator
of many of the genes involved in cardiac function, including ANP and c-fos
(Argentin et al., 1994) as well as contractile proteins such as skeletal α-actin and
cardiac α-actin (Davey, Kelly, & Wildeman, 1995; Gustafson & Kedes, 1989).
Since Phactr1 overexpression increased DNA binding activity of SRF in cultured
NRVMs, SRF could be a potential mechanism triggering the change in the skeletal
α-actin to cardiac α-actin ratio. Moreover, other SRF target genes expressed and
known to have a function in heart, were investigated at the mRNA level. In addition
to the skeletal α-actin to cardiac α-actin ratio and the β-MHC to α-MHC ratio, c-
fos and corin mRNA levels changed due to Phactr1 overexpression in cultured
NRVMS (I, Fig 9C and 9E). Other analysed SRF target genes did not become
altered due to overexpression indicating that factors other than SRF mediate the
effects of overexpression on cardiac function. It is also possible that SRF interacts
with coactivators/corepressors that modify its regulatory function. MRTFs act as
activators of SRF (Mikhailov & Torrado, 2012). The protein levels of MRTF-A
from cultured NRVMs after Phactr1 overexpression were measured using Western
blot analysis (data not shown). However, Phactr1 overexpression induced no
significant changes in the MRTF-A protein levels. Therefore, more mechanistical
studies will be needed to clarify the effects of Phactr1 overexpression on actin
regulation in heart.
The immunohistochemical evaluation revealed the presence of strong
cytoplasmic and nuclear Phactr1 staining that localized to cardiomyocytes in
normal adult rat hearts (I Fig 2E) which is in agreement with previous findings
showing various subcellular localization patterns for Phactrs (P. B. Allen et al.,
2004; Huet et al., 2013; Sagara et al., 2003, 2009; Y. Zhang et al., 2012). Allain et
al. (2012) have reported increased PHACTR1 expression levels in HUVECs after
treatment with the vascular endothelial growth factor (VEGF) isoform (VEGF-
A165) (Allain et al., 2012), in fact, PHACTR1 seems to be essential for endothelial
cell function in HUVECs since PHACTR1 depletion increased apoptosis and
impaired tube formation (Jarray et al., 2011). In our study, however, Phactr1 did
not localize to the endocardial endothelium in rat hearts when evaluated by
immunohistochemistry. Furthermore, Phactr1 overexpression in normal adult rat
57
hearts exerted no influence on capillary density during the 2 week follow-up period
(I, Fig 5D). In addition, Phactr1 gene overexpression did not result in increased
apoptosis or cell proliferation as determined by TUNEL and Ki-67 stainings,
respectively (I Fig 5B-C) with stained apoptotic bodies and cells being counted
from the hot spot areas chosen from high power fields (40x) in each sample.
5.4 The effects of Phactr1 gene delivery on cardiac function and
structure in normal and infarcted hearts (I)
Next, the possible effects of local myocardial Phactr1 gene delivery on cardiac
function and structure were evaluated. Interestingly, Phactr1 gene transfer had no
statistically significant effects on LVEF or fractional shortening (FS) (I, Fig 6A-C)
when assessed by echocardiography 3 days, 1 week or 2 weeks after Phactr1 gene
delivery (I, summary of the data in Table 2). In addition, there was no difference in
the thickness of the interventricular septum (IVS) during diastole between LacZ-
and Phactr1-treated groups (I, Fig 6D). However, the IVS during systole was
slightly but statistically significantly (P<0.05) thicker in the Phactr1-treated group
at 3 days after Phactr1 overexpression when compared to the LacZ-treated group
(I, Fig 6E). There were no significant differences in EF, FS or LV dimensions in
Phactr1-treated animals after MI when compared to LacZ-treated group (I, Fig 6F-
I). There were no statistically significant changes observed in the extent of
myocardial fibrosis, apoptosis, cell proliferation and angiogenesis in normal rat
heart LV tissues after Phactr1 gene delivery (I, Fig 5A-D). In addition, Phactr1 gene
transfer after MI had no influence on fibrosis or apoptosis (I, Fig 7E-F).
Since Phactr1 acts as an actin regulator, some changes in LV structure and
function could be expected. However, adenoviral gene delivery resulted in only a
transient Phactr1 overexpression and limited the study to investigating the early
remodeling process. To monitor longer-term effects on cardiac function, adeno-
associated virus induced overexpression would be a better model. In addition,
transgenic or knockout animal models or gene silencing methods are needed.
5.5 MI associated PHACTR1 allele is not associated with cardiac
dysfunction in humans (I)
Since PHACTR1 SNP rs12526453 had been associated with early-onset MI
(Consortium, 2009), the effect of the human PHACTR1 risk allele on cardiac
function was studied. No significant association was observed between PHACTR1
58
SNP rs12526453 and diastolic dysfunction in age and sex adjusted additive model
where the genotypic distribution of rs12526453 was compared between subjects
having normal diastolic function or mild diastolic dysfunction and those with
significant diastolic dysfunction. In addition, the association between rs12526453
and systolic function was insignificant. This data is consistent with the results from
animal experiments. However, in end-stage failing hearts, PHACTR1 expression
was up-regulated at the protein level (2.8-fold, P<0.01) (I, Fig 1E), indicating that
further studies will be required to clarify in more detail the mechanisms regulating
PHACTR1 expression in human subjects.
Overall, in this study, MI associated PHACTR1 allele was not associated
significantly with cardiac function. However, PHACTR1 SNP rs12526453 has
earlier been associated with early-onset MI and the present study demonstrated that
Phactr1 regulates the skeletal α-actin to cardiac α-actin ratio in both healthy and
infarcted heart of adult rodents. Therefore, further studies with larger populations
will be needed to investigate the association of this allele with cardiac function.
Figure 6 is a schematic presentation of the potential mechanisms regulating
Phactr1 expression and the downstream targets of Phactr1.
59
Fig. 6. Schematic presentation of the potential mechanisms regulating Phactr1
expression and the downstream targets of Phactr1.
5.6 TSC-22 is up-regulated by multiple hypertrophic stimuli and
post-MI (II)
In original publication II, the expression of TSC-22 was examined in different
models of cardiac hypertrophy and heart failure. Since previous studies have shown
increased TSC-22 mRNA levels in old spontaneously hypertensive rats (SHRs)
(Rysa et al., 2005), the TSC-22 protein levels were measured in 12-to-20-month-
old SHR and their age-matched normotensive Wistar Kyoto (WKY) rats. TSC-22
protein levels were significantly higher in SHRs (1.6-fold, P<0.05) (II, Fig 1A).
60
Then, the effect of post-infarction myocardial remodeling on TSC-22 expression
was investigated in a model of acute MI. Induction of TSC-22 in the post-MI
remodeling process is rapid and persistent since LV TSC-22 mRNA levels were up-
regulated already on day 1 following the MI (4.1-fold, P<0.001) and a significant
increase was seen also 4 weeks after MI (1.9-fold, P<0.5) when compared to sham-
operated animals (II, Fig 1B). These results are in agreement with previous gene
expression profiling studies (Stanton et al., 2000). A similar induction was seen in
TSC-22 protein levels when assessed by Western blot analysis (II, Fig 1C).
Next, the effect of acute and chronic pressure overload on TSC-22 gene
expression was studied. Ang II infusion significantly increased LV TSC-22 mRNA
levels at 6 h (12.0-fold, P<0.001) and mRNA levels remained up-regulated for two
weeks. Administration of arginine vasopressin induced a significant increase in
TSC-22 already at 1 h, and after 4 h, TSC-22 mRNA levels were markedly elevated
(1.6-fold, P<0.05 and 5.5-fold, P<0.001, respectively) (II, Fig 2A-B). The Ang II-
induced changes in TSC-22 gene expression were completely abolished by the Ang
II type 1-receptor blocker, losartan (II, Fig 2C). A similar rapid up-regulation in
response to hemodynamic stress has been seen in the expression pattern of
immediate-early genes such as c-fos, c-jun and Egr-1 (Hoshijima & Chien, 2002).
The results are summarized in Figure 7.
61
Fig. 7. A) TSC-22 total protein levels analysed by Western blot from 12 and 20 months
old WKY and SHR hearts. *P<0.05 versus WKY (Student’s t-test). The effect of MI on rat
LV tissue TSC-22 mRNA levels B) measured by RT-PCR or Northern blot and TSC-22
protein levels C) analysed by Western blot. *P<0.05, **P<0.01, ***P<0.001 versus sham
(Student’s t-test). D) The effect of Ang II administration on rat LV TSC-22 mRNA levels
as assessed by Northern blot analysis. The results are expressed as mean ± SEM.
***P<0.001 versus control (Student’s t-test). Representative Western blots and Northern
blots are shown.
Altogether, these data in conjunction with the previous findings (Rysa et al., 2005;
Stanton et al., 2000) imply that TSC-22 up-regulation is rapid and sustainable
throughout the time course of cardiac remodeling. Despite the fact that TSC-22 was
also expressed in human hearts (data not shown) both the mRNA and protein levels
remained unchanged in failing hearts when compared to the control hearts. One
possible explanation, in addition to differences between the species, might be that
elevated TSC-22 levels are needed for controlling transcriptional activity during
the remodeling process but are no longer evident in the failing heart.
62
5.7 Reduced TSC-22 expression levels after long-term treatment of
heart failure with metoprolol and hypertension with metoprolol
or losartan (II)
Beta-blockers and AT1R antagonists are important groups of drugs in the treatment
of hypertensive hypertrophy and myocardial infarction induced heart failure.
Increased TGF-β expression levels have been associated with cardiac hypertrophy
and fibrosis in different animal models of HF (J. M. Li & Brooks, 1997; Yao Sun,
Zhang, Zhang, & Ramires, 1998). The association between TGF-β1 and both the
renin-angiotensin-aldosterone and the beta-adrenergic systems have been
suggested in several studies (Brand & Schneider, 1995; Bujak & Frangogiannis,
2007; Rosenkranz, 2004). The hypertrophic response to Ang II treatment was
abolished in TGF-β1-deficient mice, indicating that the effects of Ang II on cardiac
remodelling are at least partly mediated by TGF-β1 (Schultz et al., 2002).
In original article II, post-infarction treatment with metoprolol improved LV
function and attenuated LV remodelling in rats as previously described (Mustonen
et al., 2010). The LV TSC-22 gene expression levels significantly increased after
MI (2.8-fold, P<0.001) and metoprolol treatment for 2 weeks reduced TSC-22
mRNA levels by 32% (II, Fig 3A). In addition, both the beta-blocker metoprolol
and the AT1R antagonist losartan reduced TSC-22 gene expression in rats in a
chronic pressure overload model (II, Fig 3B), which could be a result of the
beneficial effects of these drugs on the development of cardiac fibrosis (Brouri et
al., 2004; De Carvalho Frimm, Sun, & Weber, 1997; Schieffer et al., 1994). By
activating the AT1R, endogenous Ang II plays a role in the formation of fibrosis
partly by stimulating the synthesis of TGF-β1 (Brand & Schneider, 1995; Bujak &
Frangogiannis, 2007; Rosenkranz, 2004). In SHRs, cardiac hypertrophy has been
associated with increased fibrosis (Boluyt et al., 2005; Kuoppala et al., 2003).
However, it is likely that effects of losartan on TSC-22 expression are mediated by
multiple mechanisms since losartan reduced TSC-22 expression also in response to
acute pressure overload.
5.8 Hypertrophic stimuli inducible signalling pathways regulating
TSC-22 gene expression (II)
The mechanisms and signalling pathways regulating cardiac TSC-22 expression
have not been extensively studied. In this study, the hypertrophic agonist ET-1
increased both the TSC-22 mRNA and protein levels in cultured NRVMs. TSC-22
63
mRNA levels were significantly up-regulated at 4 h and were still up-regulated at
24 h. A significant increase in TSC-22 protein levels was detected at 12 h with
maximal expression level at 24 h (II, Fig 4A-B). Since MAPK pathways are known
to be activated in response to hypertrophic stimuli, including ET-1 (Rose et al.,
2010), cultured NRVMs were treated with ET-1 for 1 h and exposed to two MAPK
inhibitors, PD98059 or SB203580. Neither the ERK inhibitor PD98059 nor the
inhibitor of both p38α and p38β, SB203580, exerted any significant effect on ET-1
–induced up-regulation of TSC-22 mRNA levels (II, Fig 4C-D). However,
SB203580 alone was able to increase TSC-22 mRNA levels (II, Fig 4D).
In addition, adenoviruses expressing constitutively active MAP kinase kinase
3b(E) (MKK3bE) and wild-type p38α which cause p38 MAPK-overexpression
were injected into the LV free wall of adult Sprague-Dawley rats in order to
evaluate whether p38 MAPKs regulate cardiac TSC-22 gene expression in vivo.
Overexpression of p38 MAPK significantly increased TSC-22 expression both at
the mRNA and protein level in vivo (II, Fig 4E-F), which suggests that TSC-22 is
up-regulated in the heart via the p38 MAPK pathway in cardiac remodelling after
MI and in hypertensive hypertrophy. The interpretation of the results is difficult
since the p38 inhibitor SB203580 did not have any effect on ET-1 induced TSC-22
up-regulation in vitro, which might be a consequence of the fact that SB203580
alone was able to induce an elevation of TSC-22 gene expression.
5.9 The effect of TSC-22 overexpression on cardiac gene
expression in vivo (II)
Next, the in vivo gene transfer protocol was established in order to investigate the
direct myocardial effects of TSC-22 on cardiac gene expression. Adenovirus
mediated gene transfer locally increased TSC-22 mRNA levels in the adult rat LV,
starting at three days and lasting up to 2 weeks (7.7-fold, P<0.001 and 1.7-fold,
P<0.01, respectively) following the injections (II, Fig 6A). TSC-22 protein levels
were significantly up-regulated at 3 days (76.1-fold, P<0.001) after gene transfer
when compared to LacZ-injected control LVs (II, Fig 6B). No significant changes
in LV dimensions or cardiac function were seen at either 3 days or 2 weeks after
TSC-22 gene delivery was assessed by echocardiography (II, table 2).
TSC-22 and LacZ overexpressing hearts were immunostained to evaluate the
localization of TSC-22. In agreement with a previous study (Kato et al., 2010),
TSC-22 overexpressing hearts displayed both the nuclear and cytoplasmic
64
positivity in TSC-22 immunostaining (II, Fig 6C), indicating that TSC-22 could act
at the transcriptional level.
One key finding emerging from the study was that TSC-22 gene delivery in the
adult rat heart was able to regulate the synthesis of collagen. TSC-22
overexpression induced a significant up-regulation of Col3a1 gene expression and
a similar trend was seen in Col1a1 mRNA levels (II, Fig 6D). In previous studies,
TSC-22 has been associated with collagen expression since in cultured rat
fibroblasts, lentivirus-mediated TSC-22 overexpression enhanced TGF-β –induced
expression of collagen I (Yan, 2011), and in kidney cells, col1a2 has been shown
to be regulated by TSC-22 (Kato et al., 2010). Fibrosis is associated with altered
synthesis and degradation of type I and III collagens. This study, in conjunction
with previous findings (Kato et al., 2010; Yan, 2011), suggests that TSC-22 has a
role as a regulator of collagen synthesis during cardiac remodelling. According to
Yan, TSC-22 increases also the expression of PAI-1 and fibronectin in rat
fibroblasts (Yan, 2011). However, in this study, neither PAI-1 nor fibronectin
expression changed 2 weeks after TSC-22 gene delivery, indicating there might be
cell type specific differences in the regulation of TSC-22 gene expression.
There are some limitations in the study that need to be considered. The results
of TSC-22 gene delivery on collagen expression were assessed at the level of
transcriptional expression. Since gene expression is regulated by several
posttranscriptional and posttranslational mechanisms, the details of the expression
at the protein level need to be clarified. It would also be interesting to study the
influence of TSC-22 gene delivery on fibrosis by performing an
immunohistochemical analysis. Overall, here the molecular mechanisms of cardiac
hypertrophy and heart failure were investigated, and consequently may help in
finding new therapeutic interventions for these diseases. However, it has to be
recalled that the key findings of the study were derived from animal models, and
the translation of this kind of data to the clinic is not straightforward.
5.10 Rd3l gene expression and tissue distribution (III)
In a previous DNA microarray study, Rd3l was one of the ESTs whose expression
levels changed significantly with the transition from LVH to diastolic HF in
hypertrophied hearts of SHRs (Rysa et al., 2005). In agreement with the results
obtained by the gene expression profiling study, 12-month-old SHRs showed
higher Rd3l mRNA levels (2.1-fold, P<0.01) when compared to age-matched
normotensive WKY rats but reduced to the levels of WKY rats at the age of 20-
65
months (III, Fig 2A). When the Rd3l gene expression in Sprague-Dawley rat tissues
was examined, the highest Rd3l gene expression levels were detected in heart, eye,
thymus and brain as measured by quantitative RT-PCR analysis.
5.11 Rd3l expression levels in experimental models of hypertension
and MI in rats (III)
Cardiac Rd3l expression was studied in animal models of cardiac remodelling.
After an Ang II infusion, Rd3l expression levels were reduced starting at 6 h and
remaining low for up to 2 weeks, with the lowest levels (0.3-fold, P<0.001) being
detected at 12 h after Ang II administration (III, Fig 3A). Rd3l mRNA levels were
significantly reduced at day 1 and at 2 weeks (0.5-fold, P<0.01 and 0.6-fold,
P<0.05, respectively) post-MI (III, Fig 3B). Altogether, these results suggest that
Rd3l could have a role in LV remodelling process.
5.12 Generation of the Rd3l knockout mouse line (III)
The function of Rd3l is completely unknown. A conventional Rd3l knockout mouse
line was generated in order to characterize Rd3l in more detail. The exons 2 and 3
of the Rd3l gene and the intron between them were replaced by the LacZ-neo
cassette (III, Fig 1A) by homologous recombination in ES cells. Southern blot
analysis (III, Fig 1B) and PCR (III, Fig 1C) were used to confirm the correct
targeting of the Rd3l gene. There were no obvious phenotypic differences observed
in heterozygous or knockout mice relative to wild-type mice. Ear biopsies from the
mice were genotyped by PCR and confirmed in a few samples by Southern blot
analysis (III, Fig 1B-C).
5.13 The effects of hemodynamic pressure overload on Rd3l-
deficient mice (III)
Next, the absence of any effects attributable to Rd3l on cardiac function and
structure was evaluated in a model of hemodynamic pressure overload. Six months
old Rd3l knockout mice and their age-matched wild-type mice, which were used
as a control, were subjected to TAC for 4 weeks and their cardiac structure and
function were assessed by echocardiography. A loss of the Rd3l gene induced
abnormalities in the function of the heart in response to pressure overload. Pressure
overload induced a reduction of the LV ejection fraction both in wild type (15%)
66
and knockout (11%) mice, although this was only statistically significant in wild
type mice (P<0.05) (III, Fig 4A). The TAC procedure did not result in a significant
reduction in FS in either of the groups (III, Fig 4B). An increase in interventricular
septum (IVS) dimension during diastole due to TAC was significant both in wild
type and Rd3l knockout mice although the increase was smaller in Rd3l null mice
(46%, P<0.001 vs. 21%, P<0.01, respectively) (III, Fig 4C). The left ventricular
posterior wall (LVPW) dimension during diastole increased both in wild type and
Rd3l knockout mice due to the TAC operation although this increase was greater
in the Rd3l knockout mice (29%, P<0.01 vs. 40%, P<0.001) (III, Fig 4D). There
were no significant changes in LV volume during diastole between the groups due
to TAC (III, Fig 4E). Rd3l null mice had a shorter isovolumic relaxation time (IVRT)
(III, Fig 4F).
The inactivation of Rd3l gene affected the morphology of the heart when
animals were subjected to TAC induced pressure overload. TAC induced a
significant increase (P<0.05) in the cardiomyocyte size in LV but not in the septum
of the Rd3l knockout mice when compared to sham operated wild-type and
knockout controls (III, Fig 5A-B). In addition, there was a trend for increased LV
wall thickness and fibrosis in Rd3l mice subjected to TAC but the changes were not
statistically significant (III, Fig 5C-D). These results indicate that the absence of
Rd3l induces cardiomyocyte hypertrophy and fibrosis in loaded heart.
Finally, the effect of pressure overload on cardiac gene expression was
analysed. LV Rd3l mRNA levels were reduced significantly (50%, P<0.05) in wild
type mice due to the TAC procedure whereas Rd3l mRNA levels were undetectable
in Rd3l-knockout mice when analysed by RT-PCR (III, Fig 1D). Consistent with
previous study (Szabo et al., 2014), both ANP and BNP levels were significantly
up-regulated (6.3-fold, P<0.05 and 2.4-fold, P<0.01, respectively) in the wild-type
TAC group when compared to the wild-type sham group. Interestingly, these
increases were not significant (ANP) or were more moderate (BNP) (1.9-fold,
P<0.05) in the Rd3l knockout TAC group when compared to the sham groups (III,
Fig 6A-B). The skeletal α-actin to cardiac α-actin ratio increased significantly
(23.4-fold, P<0.01) in the wild-type TAC group (III, Fig 6C, E, G). However, this
change was not significant in the knockout TAC group. TAC resulted in an elevated
β-MHC to α-MHC ratio in both the wild-type (3.8-fold, P<0.01) and knockout (3.4-
fold, P<0.01) groups (III, Fig 6D, F and H). These results suggest that a loss of
Rd3l gene is associated with dysregulated activation of the fetal gene program in
the heart.
67
Natriuretic peptides ANP and BNP are cardioprotective hormones that cause
vasodilatation and exert hypotensive actions (Pandey, 2011; Ruskoaho et al., 1991).
Hemodynamic overload and cardiac remodelling induce the synthesis and secretion
of natriuretic peptides in the heart and they are used as diagnostic markers in HF
(Kerkelä et al., 2015). ANP binds to guanylyl cyclase/natriuretic peptide receptor-
A (GC-A/NPRA) which induces an elevation of intracellular cyclic guanosine
monophosphate (cGMP) and an inhibition of cardiac hypertrophy and fibrosis
(Pandey, 2011). The inhibition of cGMP hydrolysis by phosphodiesterase 5A
(PDE5A) has been shown to exert a positive impact on cardiac function (Kass,
2012). The PDE5 inhibitor, sildenafil, was able to suppress hypertrophy in mice
with TAC induced pressure-overload (Takimoto et al., 2005). PDE5 overexpression
led to adverse LV remodelling post-MI (Pokreisz et al., 2009). In addition,
myocyte-specific PDE5 overexpression impaired cardiac function and increased
fibrosis when the mice were subjected to TAC induced pressure overload but the
effects were reversed by PDE5 inhibition (M. Zhang et al., 2010).
RD3 is an important paralog of Rd3l. RD3 proteins are involved in the
regulation of guanylyl cyclase activity and cGMP levels in retina (Peshenko et al.,
2011). Since the ANP response in Rd3l null mice was attenuated, our results
suggest that the absence of Rd3l may induce a smaller increase in the levels of
cGMP in response to pressure overload. A loss of Rd3l function in pressure
overloaded heart could lead to increased myocyte hypertrophy and cardiac
dysfunction due to reduced cGMP levels in myocardium. However, further studies
will be required to clarify the function of Rd3l in cardiac hypertrophy.
In addition, the limitations of gene modification technology must be taken into
consideration. The phenotype produced by genetic manipulation through
constitutive knockout may not truly reflect the functional role of target gene in a
studied pathological condition. Secondary, compensatory, or off-target effects can
lead to misinterpretations. Non-coding intron regions, when located between the
target exons, are also replaced by the targeting construct and these might contain
important regulatory areas for other genes.
68
69
6 Summary and conclusions
This study characterized the roles of three novel factors, Phactr1, TSC-22 and Rd3l,
in different experimental models of cardiac hypertrophy and failure.
1. Phactr1 expression was rapidly down-regulated post-MI in the left ventricles,
likely due to the direct mechanical stretching of cardiac myocytes. Phactr1
overexpression changed the skeletal α-actin to cardiac α-actin ratio in vivo both
in healthy and in infarcted rat hearts, as well as in vitro in cultured
cardiomyocytes. Phactr1 could regulate the switch in the actin isoform due to
SRF since overexpression of Phactr1 led to enhanced SRF DNA binding
activity.
2. A myocardial injury and multiple hypertrophic stimuli induced a rapid up-
regulation of TSC-22 in rat heart. TSC-22 overexpression increased col3a1
gene expression in adult rat heart, suggesting that TSC-22 could regulate
collagen synthesis in heart and could be a target for preventing the formation
of cardiac fibrosis.
3. Hypertrophied hearts of SHRs expressed lower levels of Rd3l mRNA with
aging. Rd3l expression was also reduced in Ang II –induced pressure overload
and post-MI. The absence of Rd3l led to increased cardiomyocyte hypertrophy
and cardiac dysfunction in response to the TAC-induced pressure overload,
suggesting that Rd3l may be involved in the pathological hypertrophic
response in the heart.
70
71
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Original articles
I Kelloniemi A., Szabo Z., Serpi R., Näpänkangas J., Ohukainen P., Tenhunen O., Kaikkonen L., Koivisto E., Bagyura Z., Kerkelä R., Leosdottir M., Hedner T., Melander O., Ruskoaho H.*, Rysä J.* (2015). The early-onset myocardial infarction associated PHACTR1 gene regulates skeletal and cardiac alpha-actin gene expression. PLoS ONE 10(6). http://doi.org/10.1371/journal.pone.0130502.
II Kelloniemi A., Aro J., Näpänkangas J., Koivisto E., Mustonen E., Ruskoaho H., Rysä J. (2015). TSC-22 up-regulates collagen 3a1 gene expression in the rat heart. BMC Cardiovascular Disorders, 15(1). http://doi.org/10.1186/s12872-015-0121-2.
III Kelloniemi A., Szabo Z., Serpi R., Aro J., Soininen R., Ruskoaho H.*, Rysä J.* Genetic retinal degeneration 3-like (Rd3l) deficiency induces cardiac dysfunction in response to pressure overload. Manuscript.
Reprinted with permission from PLOS (I) and BioMed Central (II) under the
Creative Commons Attribution License.
Original publications are not included in the electronic version of the dissertation.
96
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