Circulation Research

Background: Arrhythmogenic cardiomyopathy (ACM) is a genetic and phenotypically heterogeneous myocardial disorder characterized by progressive cardiomyocyte loss, immune cell infiltration, and fibro-fatty replacement of the ventricular myocardium, with an increased risk of sudden cardiac death (SCD), predominantly caused by mutations in cardiac desmosomal genes including PKP2, DSP, and DSG2. We previously described the pivotal role of NF{kappa}B and CCR2+ cardiac macrophage-triggered inflammation in ACM pathogenesis. Methods: WT or Dsg2mut/mut mice were treated with either isotype control or anti-CD14 antibody once a week for the described treatment period (4 or 8 weeks). At the end of the treatment period, disease characteristics were assessed by echocardiography, electrocardiography, histology, immunofluorescence, positron emission tomography (PET) imaging and single-cell transcriptomics. Results: Here, we demonstrate the efficacy of neutralizing CD14 signaling, an important mediator of inflammatory macrophage activation, in attenuating ACM disease in vivo. Additionally, we elucidate shifts in the cellular and transcriptomic landscapes that occur following anti-CD14 antibody treatment in a well-established mouse model of ACM and identify substantial reductions in inflammatory macrophage and pro-fibrotic fibroblast populations. Conclusion: This study provides evidence that blockade of CD14 can attenuate the ACM disease phenotype. It may do so by inhibiting macrophage-based activation and inflammation, while also altering the transcriptional state of other important cell types. Collectively, these findings suggest that CD14 inhibition may be an effective option for ACM, which should be explored in early-phase clinical studies.

Cardiomyocyte hypertrophy is a leading clinical predictor of heart failure, yet newly identified candidate genes often remain disconnected from the signaling mechanisms that govern cardiomyocyte growth. We developed a computational-experimental pipeline that integrates genome-scale mouse knockout phenotypes with a logic-based differential equation model of hypertrophic signaling. Among 9,605 genes evaluated by the International Mouse Phenotyping Consortium, 939 knockout lines induced abnormal heart morphology. Directional curation of hypertrophy-related sub-phenotypes followed by interaction-based network expansion mapped 37 genes to the signaling model. Virtual knockdown screening identified five candidates with concordant in vivo and in silico effects: LRIG1 and CBL as predicted negative regulators and VAV2, RASA1, and LEPR as predicted positive regulators. Mechanistic subnetwork analysis linked these candidates to distinct receptor-proximal, Ras, PI3K-AKT, and MAPK signaling axes. In neonatal rat cardiomyocytes, siRNA-mediated depletion of VAV2, RASA1, or LEPR reduced phenylephrine-induced cell growth, supporting their cell-autonomous contribution to hypertrophy. Quantitative phenotyping further validated the predicted decreased cardiac hypertrophy for VAV2 and LEPR knockouts but identified potential age-dependent mechanisms for RASA1 knockout. Overall, this study establishes the application of network models to translate from in vivo phenotypic screens into pathway mechanisms.

Pulmonary hypertension (PH) is a progressive and fatal disease characterized by pulmonary vascular remodeling, inflammation, and immune dysregulation. Myeloid-derived suppressor cells (MDSCs) and macrophages contribute to PAH pathobiology; however, the molecular regulators of their pathological activation remain poorly defined. The triggering receptor expressed on myeloid cells 2 (TREM2) is an immunomodulatory receptor that shapes myeloid cell metabolism, survival, and immunosuppressive function, yet its role in PH has not been investigated. Methods: Single-cell RNA sequencing (scRNA-seq) data from human pulmonary artery tissue (GSE210248; n=3 PAH, n=3 donors) were analyzed to characterize TREM2 expression across cell populations. Wild-type (WT) and global TREM2 knockout (TREM2 KO) mice were exposed to chronic hypoxia (10% FiO2, 28 days). Hemodynamic, histological, flow cytometric, and ex vivo functional assessments were performed. TREM2 expression was measured by flow cytometry in circulating MDSCs from PAH patients (n=22) and healthy controls (n=13). Results: TREM2 was markedly enriched in monocyte/macrophage populations in PH pulmonary arteries and TREM2-high immune cells exhibited transcriptional downregulation of chemotaxis programs and upregulation of antigen processing and MHC II presentation pathways. TREM2 deficiency significantly attenuated hypoxia-induced RVSP increase, right ventricular dysfunction, pulmonary inflammation, and vascular remodeling. MDSCs from TREM2 KO mice exerted significantly less suppression of CD4+ and CD8+ T cell proliferation. TREM2 was significantly elevated in circulating MDSCs from PAH patients and showed a directional association with hemodynamic severity. Conclusions: TREM2 is a novel regulator of myeloid-driven immunosuppression and vascular remodeling in PAH and warrants investigation as a therapeutic target and biomarker.

Background: Calcific aortic valve disease (CAVD) lacks disease-modifying therapy. LDL-cholesterol lowering does not attenuate valvular calcification, suggesting cholesterol-independent drivers. Thus, we tested whether ceramide accumulation drives CAVD and whether inhibiting sphingolipid de novo synthesis is therapeutic. Methods: We integrated lipidomics and proteomics of calcified and non-calcified human aortic valves with matched plasma. Mechanistic effects of ceramides were tested in primary human valvular interstitial cells (VICs). Therapeutic efficacy of serine palmitoyltransferase (SPT) inhibition with Myriocin was evaluated in ApoE-/- mice with PCSK9DY-AAV-driven hyperlipidemia on Western diet using preventive treatment and therapeutic initiation after echocardiographically verified gradient elevation. Myriocin was additionally tested in a normolipidemic wild-type aortic valve wire-injury model. Hemodynamics, valve structure, lipid composition, and cell-state transitions were assessed by echocardiography, histology, lipidomics, and single-cell RNA sequencing. Results: Calcified human valves showed enrichment of long-chain ceramides linked to NF-{kappa}B, endothelial-to-mesenchymal transition (EndMT), and ER-stress/unfolded protein response (UPR) programs, whereas matched plasma sphingolipids were not elevated. In hVICs, long-chain C18 ceramide induced GRP78/BiP, CHOP, and ATF4, activated NF-{kappa}B, and promoted dose-dependent calcification. In vivo, SPT inhibition with Myriocin lowered valvular ceramides, reduced leaflet inflammation and mineralization, and improved cusp separation and transvalvular hemodynamics without lowering plasma LDL-cholesterol. In a therapeutic protocol initiated after gradient elevation, Myriocin halted further hemodynamic progression, providing the first evidence that de novo sphingolipid synthesis can be targeted after established CAVD onset in vivo. Myriocin also attenuated injury-induced stenosis in normolipidemic mice. Single-cell RNA sequencing showed reduced NF-{kappa}B/EndMT and ER-stress signatures and shifted VIC states away from osteogenic phenotypes. Conclusions: Human valve lipidomics and human VIC experiments identify ceramide-driven lipotoxicity as a driver of an ER-stress-NF-{kappa}B-EndMT axis in CAVD. In vivo, de novo sphingolipid synthesis is an actionable, LDL-independent target capable of modifying established hemodynamic disease progression, supporting SPT inhibition as a tractable strategy for medical CAVD therapy.

Background: Calcific aortic valve disease (CAVD) is the most common valvular heart disease in older adults and currently has no approved pharmacological therapy to prevent or slow disease progression. Aortic valve replacement, either surgically or by transcatheter aortic valve implantation (TAVI), therefore remains the only effective treatment for severe CAVD. Monocytes play an important role in driving inflammation and disease progression in CAVD. As the disease progresses and the aortic valve becomes increasingly stenotic, circulating monocytes passing through the narrowed valve are repeatedly exposed to pathological haemodynamic forces, including markedly elevated shear stress, before their recruitment into the valve tissue. However, how exposure to these mechanical forces reprograms circulating monocytes influences their subsequent responses within the valve remain poorly understood. Methods and Results: In this study, we used an engineered model of aortic valve stenosis combined with phosphoproteomic profiling to investigate how prolonged exposure to pathological shear stress reprograms circulating monocytes and influences their subsequent phenotype and function following recruitment into the valve matrix. We further used TAVI as a unique clinical model to determine whether restoration of physiological haemodynamics in patients with severe aortic stenosis reverses the shear-induced monocyte phenotype observed in our experimental model. We found that prolonged exposure of monocytes to pathological shear stress induced extensive remodelling of the proteomic and phosphoproteomic landscape, with enrichment of pathways associated with cellular metabolism, cytoskeletal organisation, and inflammatory signalling. Kinase activity analysis further identified increased protein kinase C (PKC) activity accompanied by suppression of AKT signalling. Consistent with these molecular changes, pathological shear stress increased actin polymerisation, mitochondrial membrane potential, intracellular calcium signalling, and PKC activity. Using a bioengineered extracellular matrix model that recapitulates the glycosaminoglycan-rich microenvironment of the stenotic aortic valve we found that prior exposure to pathological shear stress altered monocyte-to-macrophage differentiation, reducing oxidised LDL uptake and foam-cell formation while promoting co-expression of CD80 and CD163, indicative of a mixed macrophage phenotype. Finally, using a myeloid-specific Piezo1 knockout mouse model, we identified Piezo1 as a key mechanosensor linking pathological shear stress to PKC activation, mitochondrial responses, and persistent changes in monocyte phenotype following migration into the extracellular matrix. Conclusions: These findings establish a mechanistic link between abnormal valve haemodynamics, metabolic and inflammatory reprogramming of circulating monocytes, extracellular matrix remodelling, and immune dysregulation during CAVD progression, highlighting monocyte mechanotransduction and downstream PKC/Piezo1 signalling as potential therapeutic targets.

Aldosterone is a key regulator of systemic sodium, potassium, and fluid homeostasis. Chronic elevation of aldosterone, as observed in primary aldosteronism, chronic heart and kidney diseases, promotes cardiac hypertrophy, inflammation, fibrosis, and heart failure, which are further enhanced in aging. Although these pathological effects are primarily attributed to the mineralocorticoid receptor (MR), emerging evidence suggests roles for nonclassical G protein-coupled receptor (GPCR) signaling. We identified lysophosphatidic acid receptor 2 (LPAR2) as a novel GPCR candidate that mediates aldosterone signaling in cardiomyocytes. Using AC16 human cardiomyocyte cells and reporter gene assays, we demonstrate that aldosterone activates a Gi/o-dependent GPCR pathway. Pharmacological inhibition of LPAR2 internalization confirms its specific reaction to aldosterone. Functional studies revealed that aldosterone-induced cardiomyocyte injury requires both MR and LPAR2, where specific antagonists to both receptors reduced the ability of aldosterone to induce collagen expression and cell death markers. These findings uncover a previously unrecognized non-classical mechanism of aldosterone action in the heart and highlight LPAR2 as a promising therapeutic target for aldosterone-driven cardiovascular disease.

Background: Activation of the renin-angiotensin system (RAS) contributes to aortic diseases caused by fibrillin-1 haploinsufficiency (Fbn1C1041G/+). However, whether RAS activation influences mitral valve disease associated with FBN1 variants remains undefined. This study determined whether inhibition or augmentation of the RAS affects mitral valve pathology in Fbn1C1041G/+ mice. Methods: Angiotensinogen (AGT) antisense oligonucleotides (ASOs) were administered for 12 weeks to inhibit the RAS in male and female Fbn1C1041G/+ mice. To augment the RAS, mice were infused with angiotensin II (AngII; 1,000 ng/kg/min) for 28 days. Mitral valve and heart function were monitored by ultrasound. At termination, hearts were dissected free and tissue sectioned to assess mitral valve leaflet thickness and pathology. Results: Mitral valve leaflet thickness was significantly increased in Fbn1C1041G/+ mice compared to Fbn1+/+ littermates of both sexes. ASO-mediated AGT inhibition did not alter this phenotype despite markedly reduced plasma AGT concentrations. AngII infusion increased mitral valve leaflet thickness in Fbn1C1041G/+ mice with increased proteoglycan and collagen content, while exerting minimal effects in Fbn1+/+ mice. Twenty-five percent of AngII-infused Fbn1C1041G/+ mice died of non-vascular causes. Ultrasound showed mitral valve dysfunction in AngII-infused Fbn1C1041G/+ mice. Grossly expanded left atria were common in AngII-infused Fbn1C1041G/+ mice. These markedly enlarged left atria contained increased fibrosis, macrophage accumulation, and platelet-rich masses. Conclusions: Mitral valves of Fbn1C1041G/+ mice did not respond to AGT inhibition but were markedly more susceptible to AngII infusion, with greater increases in thickness and compositional changes than mitral valves of Fbn1+/+ mice. In addition, AngII promoted mitral valve dysfunction that were associated with pronounced left atrial pathology.

Myocardin (MYOCD) is the principal trigger-switch for vascular smooth muscle cell (VSMC) growth arrest and the cyto-contractile program of differentiation. While much is known about MYOCD-dependent VSMC differentiation, limited information exists as to its transcriptional regulation. Here, we report moderate mRNA expression of Myeloid Ecotropic viral Integration Site 1 (MEIS1) in both human and mouse VSMCs. MEIS1 mRNA is reduced in parallel with myocardin mRNA and protein under conditions of VSMC de-differentiation. Loss- and gain-of-Meis1 expression studies in cultured human VSMCs and the mouse carotid artery support MEIS1 as an activator of myocardin and VSMC differentiation. CRISPR-mediated knockout of the endogenous Meis1 gene in vitro and elicited lower levels of VSMC contractile markers and an increase in growth rate. Similarly, Femoral artery wire injury, in mice lacking Meis1 showed and increased of neointima formation. Mechanistically, we identified a conserved MEIS1 response element in the proximal promoter of myocardin, that appears to contribute to the promoter activity, suggesting a potential regulatory interaction. These results suggest a previously unrecognized role for the homeodomain protein MEIS1 in the activation of myocardin and the quiescent, VSMC differentiated state.

Background: Sodium-glucose cotransporter-2 (SGLT2) inhibitors reduce cardiovascular mortality and chronic kidney disease (CKD) progression in cardiovascular-kidney-metabolic (CKM) syndrome, but this benefit derives primarily from reductions in heart failure and cardiovascular mortality rather than in atherothrombotic events. Sotagliflozin, which inhibits both intestinal SGLT1 and renal SGLT2, is the only drug in this class shown to lower rates of myocardial infarction and stroke in CKD. However, its mechanism remains unclear, and its effectiveness in non-diabetic CKD has not been studied. We hypothesized that dual SGLT1/2 inhibition reprograms systemic substrate utilization toward fatty acid oxidation, which may partially account for this protective effect. Methods: CKD was induced in male low-density lipoprotein receptor-deficient mice by 5/6 nephrectomy. Sham and CKD mice received a high-fat diet and drinking water containing sotagliflozin, empagliflozin, or vehicle for 16 weeks, at doses that produced equivalent fractional excretion of glucose. We quantified atherosclerosis en face and in the aortic sinus. Indirect calorimetry, echocardiography, hepatic RNA sequencing, plasma acylcarnitine profiling, and in vivo deuterium labeling of palmitate were performed. Results: At matched levels of glucosuria and plasma total cholesterol, sotagliflozin decreased body mass, atherosclerosis burden, triglycerides, and TNF- more than empagliflozin, and raised postprandial total GLP-1 approximately 3-fold, while both drugs similarly improved albuminuria and diastolic function. Sotagliflozin increased energy expenditure independent of body mass and lowered respiratory exchange ratio despite compensatory hyperphagia. Sotagliflozin reduced hepatic lipogenic genes and de novo lipogenic flux, while increasing {beta}-oxidation and ketogenesis; empagliflozin only activated the oxidative pathway. Conclusions: In experimental CKM syndrome, dual SGLT1/2 inhibition reduces atherosclerosis and metabolic syndrome more effectively than selective SGLT2 inhibition and is associated with reprogramming of hepatic lipid metabolism. These results suggest that sotagliflozin could be an attractive candidate for mitigating atherosclerotic risk in non-diabetic CKD.

Background: Calcific aortic valve disease (CAVD) is characterized by progressive inflammatory and fibrocalcific remodeling. Although valvular interstitial cells (VICs) are generally considered to drive fibrosis and osteogenic remodeling, whether injury-activated VICs mount endogenous protective responses that preserve the valvular interstitial microenvironment and restrain calcification remains unknown. Methods: We performed spatial transcriptomic profiling of aortic valves in a mouse model of endothelial injury-induced CAVD to define early injury-responsive programs within the valvular interstitium. The cellular origin and spatial distribution of candidate protective factors were examined by immunohistochemistry and lineage tracing, and their relevance to human disease was assessed using stenotic aortic valves. The functional role of CTHRC1 was investigated using genetic Cthrc1 deficiency combined with longitudinal hemodynamic assessment, histological analysis, and spatial transcriptomic profiling. Results: Spatial transcriptomics identified Cthrc1 as a prominent component of an early injury-induced stromal response in the expanding valvular interstitium. CTHRC1 was strongly expressed in activated VICs within thickened murine valve leaflets and human stenotic aortic valves. Lineage tracing demonstrated that the expanded VIC population arose predominantly from PDGFR{beta}+ resident interstitial cells, with minimal endothelial contribution. Despite comparable early hemodynamic responses to endothelial injury, Cthrc1 deficiency exacerbated chronic valvular calcification. Spatial profiling of Cthrc1-deficient valves revealed pronounced interstitial accumulation of galectin-3+ foamy macrophages, accompanied by mitochondrial respiratory-chain signature loss and cell death-associated pathway activation. These findings indicate that transient CTHRC1 induction after endothelial injury defines an endogenous stromal protective response that preserves the valvular interstitial microenvironment and limits macrophage-associated tissue injury and subsequent dystrophic calcification. Conclusions: Injury-activated VICs are not merely effectors of pathological remodeling, but can engage an endogenous tissue-protective response through CTHRC1. These findings identify a previously unrecognized stromal defense mechanism linking endothelial injury to macrophage-associated inflammatory remodeling and dystrophic calcification and suggest CTHRC1-dependent stromal protection as a potential therapeutic axis for limiting CAVD progression.

Branched-chain amino acids (BCAA) have been implicated in diabetes and heart failure, leading to ongoing clinical trials with inhibitors of BCKDK, a key regulator of BCAA catabolism. We have previously shown that these inhibitors promote vasodilation and lower blood pressure, well-known cardioprotective effects, but how this occurs remained unclear. We show here, using explanted vessels, in vivo hemodynamics and telemetry, and genetically modified mice, that the vasodilatory effect of BCKDK inhibitors is direct, rapid, independent of nitric oxide, independent of BCAA catabolism, and most strikingly, independent of BCKDK itself. Instead, we demonstrate, using structural and biochemical studies, that BCKDK inhibitors directly antagonize the angiotensin II type I receptor (AT1R) and consequent angiotensin-mediated vasoconstriction. These data demonstrate a strong off-target effect of BCKDK inhibitors, independent of BCAA or BCKDK, which may explain their cardioprotective effects but also questions if this protection would be additive to existing AT1R blockers.

Background: Murine models are widely used to investigate cardiovascular disease (CVD), yet many established models rely on invasive surgery or genetic manipulation to induce hyperlipidemia and therefore may not fully capture the gradual cardiovascular consequences of mutant hematopoiesis. Tie2-Cre/-FF1/- (Tie2FF1) mice express JAK2V617F mutation in both hematopoietic and endothelial cells and develop spontaneous CVD on a standard chow diet. Methods: We applied a comprehensive, non-invasive cardiovascular phenotyping protocol to 1-year-old Tie2FF1 mice and age-matched controls. Assessments included transthoracic echocardiography, coronary flow reserve by Doppler ultrasound, quantitative analysis of coronary arteriolar structure and perivascular fibrosis, endocardial histology and subendocardial collagen deposition, and histologic evaluation of pulmonary and hepatic congestion. Results: Tie2FF1 mice demonstrated left ventricular dilation, increased cardiac mass, and mildly reduced systolic function without obstructive epicardial coronary disease. Coronary microvascular remodeling was evident by arteriolar narrowing and increased perivascular fibrosis, while coronary flow reserve was markedly reduced in an exploratory cohort. Endocardial endothelial disruption and increased subendocardial fibrosis were also observed. In addition, Tie2FF1 mice showed increased lung and liver weights, pulmonary fluid accumulation, alveolar septal thickening, pulmonary vascular fibrosis, hepatic sinusoidal dilatation, and centrilobular hepatocyte swelling, providing objective evidence of clinically relevant heart failure. Significance: These findings establish Tie2FF1 mice as a spontaneous, non-invasive model with features of coronary microvascular and endocardial endothelial dysfunction and heart failure with mildly reduced left ventricular ejection fraction. The integrated approach described here provides a practical framework for comprehensive murine cardiovascular phenotyping beyond traditional atherosclerosis- and surgery-based models.

Pulmonary arterial hypertension (PAH) is characterized by the hyperproliferative phenotype of pulmonary arterial smooth muscle cells (PAVSMCs) and extensive extracellular matrix (ECM) remodeling. Vacuolar protein sorting 34 (VPS34), a Class III Phosphatidylinositol-3 Kinase (PI3K), regulates cell proliferation, but its specific function in pulmonary vascular remodeling remains poorly understood. We aim to determine the role of VPS34 activation and regulation in PAVSMC proliferation, matrix deposition, and the progression of PAH. First, we found a marked decrease in the inhibitory phosphorylation of VPS34 at Ser164 (P-S164-VPS34), indicative of constitutive VPS34 activation, in remodeled pulmonary arteries (PAs) from human PAH patients and male mice exposed to Sugen/Hypoxia (SuHx). In human PAH PAVSMCs, siRNA-mediated knockdown of VPS34 or pharmacological inhibition via the selective inhibitor SAR405 significantly blunted cell proliferation and reduced the production of fibronectin, a major component of the remodeled ECM. Mechanistically, we found that Akt activation in PAH PAVSMCs promotes VPS34 activation; Protein Phosphatase 1 Catalytic Subunit Alpha is a potential effector in VPS34 activation; and active VPS34 led to the activation of the mTOR/S6 signaling pathway with tuberous sclerosis complex 2 downregulation. Finally, in vivo treatment with SAR405 attenuated right ventricular systolic pressure, right ventricular hypertrophy, and pulmonary vascular remodeling in SuHx mice, while concurrently decreasing vascular fibronectin deposition. Our study demonstrates that VPS34 activation, driven by an Akt-mediated loss of the inhibitory P-S164, is crucial in PAVSMC proliferation and fibrotic vascular remodeling in PAH. Targeting the VPS34 axis represents a promising anti-remodeling therapeutic strategy for the treatment of PAH. Keywords: Pulmonary arterial hypertension, vacuolar protein sorting 34, pulmonary vascular remodeling, pulmonary arterial vascular smooth muscle

Obesity is associated with hypothalamic inflammation, leptin resistance and increased cardiometabolic risk, but the neuroimmune signals linking nutrient excess to these outcomes remain incompletely defined. Here we show that diet-induced obesity is accompanied by local complement activation in the mouse hypothalamus, leading to C3a generation that signals through C3a receptor (C3aR) on leptin receptor (ObRb)-expressing neurons and blunts leptin signaling. Deletion of C3aR in ObRb-expressing neurons preserves leptin responsiveness, reduces food intake and weight gain, and improves glucose homeostasis during dietary challenge. Systemic pharmacological C3aR targeting induces weight loss and improves leptin responsiveness in established obesity. Genetic or pharmacological C3aR targeting also attenuates obesity-associated diastolic dysfunction and myocardial fibrosis; pair-feeding experiments reveal an additional component of cardiac protection beyond reduced weight gain, associated with lower cardiac sympathetic innervation. In humans, circulating complement activation markers are elevated in obesity and decline after bariatric surgery. Together, our findings identify C3aR signaling in ObRb-expressing neurons as a neuroimmune pathway contributing to hypothalamic leptin resistance and obesity-associated cardiac remodeling, highlighting complement signaling as a potential therapeutic target in cardiometabolic disease.

Objective: Mitochondrial oxidative capacity in striated muscle is governed by the PGC-1/ERR transcriptional axis, which controls not only steady-state respiration but the capacity to expand energy production when demand rises. Whether this reserve function requires dedicated downstream effectors, and whether its loss is detectable at rest, remains unclear. We asked whether Perm1, a striated muscle-specific PGC-1/ERR-induced regulator, is required cell-autonomously for cardiac bioenergetic reserve. Methods: We generated cardiomyocyte-specific Perm1 knockout mice using alphaMHC-nCre, complemented by an adult tamoxifen-inducible alphaMHC-MerCreMer model, and assessed cardiac development, structure, and function longitudinally through 12 months of age in both sexes. We evaluated mitochondrial function by high-resolution respirometry, transmission electron microscopy, and molecular profiling. We tested energetic capacity under load by treadmill exercise with tissue ATP quantification and by beta-adrenergic stimulation of cultured neonatal cardiomyocytes. Results: Perm1 deletion did not perturb embryonic cardiac development, and neither constitutive nor adult-onset deletion impaired cardiac structure, systolic function, or diastolic function through 12 months. Despite this preserved resting phenotype, mitochondrial respiration was reduced by 20 - 25% across complex I- and complex I+II-supported conditions, without changes in citrate synthase activity, mtDNA copy number, or OXPHOS subunit abundance. Instead, the MICOS components IMMT (MIC60) and CHCHD3 (MIC19) were selectively reduced, and mitochondrial subpopulations shifted toward fewer subsarcolemmal and more interfibrillar mitochondria, with unchanged total mitochondrial density. Functionally, Perm1-deficient mice of both sexes showed reduced treadmill capacity at 6 and 12 months and failed to maintain cardiac ATP during exercise at a submaximal workload, while skeletal muscle ATP and plasma lactate were unaffected. This deficit was cardiomyocyte-autonomous: beta-adrenergic stimulation increased ATP content in control cardiomyocytes, but Perm1 knockdown reduced this response. Conclusions. Perm1 is a cardiomyocyte-intrinsic determinant of bioenergetic reserve, dispensable for resting cardiac function but required to expand ATP production under increased demand. These findings identify a mode of metabolic regulation that is invisible to resting functional phenotyping.

Inflammatory T-cell infiltration is widely considered a hallmark of cardiac immune-mediated tissue injury, yet whether inflammation alone is sufficient to cause cardiac damage remains unclear. Using a spontaneous genetic model of immune checkpoint inhibitor myocarditis, we show that cardiac immune infiltration and tissue injury are separable processes. CD4+ T-cells promote disease by licensing pathogenic CD8+ T-cell responses through CD40L signaling, whereas perforin-dependent CD8+ cytotoxicity is specifically required to induce cardiomyocyte death and cardiac arrhythmias. Loss of perforin prevented cardiac injury and rescued survival despite persistent myocardial inflammation, demonstrating that inflammatory infiltration is insufficient to produce lethal myocarditis in the absence of a cytotoxic effector program. CD40L blockade similarly attenuated pathogenic CD8+ T-cell activation, myocardial inflammation, and mortality. These findings identify a cooperative CD4-CD8 T-cell circuit that governs autoimmune cardiac injury and establish that acquisition of cytotoxic effector function, rather than inflammation alone, determines the transition from immune infiltration to tissue destruction.

Background: Autophagy is a homeostatic pathway supporting stress adaptation and is dysregulated in atherosclerosis. Its potential as a biomarker or therapeutic target in atherosclerotic vascular disease (ASVD) remains incompletely defined. We measured autophagic flux in peripheral blood mononuclear cells (PBMCs) from patients with peripheral arterial disease (PAD) or carotid stenosis (CS), compared with healthy controls, and explored clinical outcome associations. Methods: Ninety-four patients with PAD or CS and 19 healthy controls were studied. Autophagic flux was quantified from fresh blood using a validated ex vivo chloroquine inhibition ELISA measuring LC3BII accumulation. Major adverse cardiovascular events (MACE) and major adverse limb events (MALE) were ascertained over a median follow up of 828 days. Results: The ASVD cohort comprised claudication (n = 16), chronic limb threatening ischemia (CLTI; n = 49), and CS (n = 29). Autophagic flux was higher in ASVD than controls (mean 281.4 vs. 182.3 ng LC3BII/mg protein/h; p < 0.0001) and remained independently associated after multivariable adjustment. Within CLTI, concurrent infection was associated with lower flux (p = 0.001), approaching control levels (p = 0.327). In CLTI, higher flux quartiles were associated with lower MACE risk, most strongly for quartile 3 (hazard ratio 0.07 vs. quartile 1, 95% CI 0.01 to 0.50; p = 0.009). Conclusion: Autophagic flux is elevated in PBMCs from ASVD patients, independent of age and sex. Attenuated flux in CLTI with concurrent infection may indicate autophagic exhaustion in advanced disease. The association between higher flux and lower MACE in CLTI suggests prognostic utility, warranting evaluation in larger prospective studies.

Background Takotsubo cardiomyopathy (TTC) is a stress-induced cardiomyopathy characterized by acute cardiac dysfunction, inflammation, and hypertrophy, yet no therapy directly targets the underlying myocardial injury. Clinical studies have reported elevated circulating Angiotensin II (Ang II) levels in TTC patients, suggesting dysregulation of the renin-angiotensin system (RAS). Given the established cardioprotective effects of Angiotensin-(1-7) [Ang-(1-7)] in other cardiovascular diseases, we hypothesized that oral administration of Ang-(1-7) could attenuate acute cardiac remodeling during TTC. Methods Female C57BL/6J mice were subjected to a single high-dose isoproterenol (ISO) injection (300 mg/Kg, intraperitoneal) to induce TTC and received daily oral treatment with Ang-(1-7) complexed with hydroxypropyl {beta}-cyclodextrin [Ang-(1-7)-CD] or vehicle (CD), for 4 days, beginning one day before ISO administration. Cardiac proteome alterations were characterized by tandem mass tag (TMT)-based quantitative proteomics. Cardiac hypertrophy was assessed by heart weight normalized to tibial length and cardiomyocyte cross-sectional area. Myocardial inflammation was evaluated by histopathology, CD68 immunostaining, and flow cytometric analysis of infiltrating leukocyte populations. Results We observed a distinct cardiac proteome signature in Ang-(1-7)-treated ISO mice, predicting inhibition of pathways associated with cardiac hypertrophy and adverse remodeling. These molecular changes were accompanied by reduced heart weight normalized to tibial length and smaller cardiomyocyte cross-sectional area compared with vehicle-treated ISO mice. Oral Ang-(1-7) also attenuated myocardial inflammation, as evidenced by lower inflammatory scores, reduced CD68+ macrophage infiltration, decreased numbers of CD45+ leukocytes, and marked suppression of Ly6G+ neutrophil and CCR2+ monocyte recruitment to the heart. These protective effects were associated with improved survival following ISO challenge. MS data are available via ProteomeXchange (PXD082872). Conclusions Oral administration of Ang-(1-7) attenuated acute cardiac hypertrophy and inflammation in experimental TTC while inducing cardiac proteome changes consistent with reduced adverse remodeling. These findings identify activation of the protective RAS axis as a promising therapeutic strategy for limiting myocardial injury during TTC.

The adrenergic response is a fundamental mechanism that regulates heart rate (chronotropy), cardiac contractility (inotropy) and relaxation (lusitropy). Adrenergic stress is also a recognized trigger of arrhythmia in disease. Yet, our understanding of the underlying molecular basis remains incomplete. Protein kinase A (PKA) and the calcium/calmodulin-dependent kinase II (CaMKII) phosphorylate multiple targets proposed to participate in the adrenergic response, including the GTP-binding protein Rad, phospholamban (PLB) and ryanodine receptor 2 (RyR2). Here we demonstrate that phosphorylation of both Rad and PLB is necessary for inotropy and lusitropy. We show that changes in cardiac contractility and relaxation are primarily dependent on intracellular calcium handling. Finally, we report that Rad and PLB control stress-induced arrhythmogenesis, despite the phosphorylation of other pro-arrhythmic targets. We have identified the essential molecular components of the adrenergic response, resolving a long-standing debate in cardiac excitation-contraction coupling and refining current models of sympathetic regulation in health and disease.

Background: Macrophage foam cell formation is a central event in atherosclerosis. Although protein ubiquitination is increasingly recognized as a regulator of macrophage lipid handling, whether deubiquitinating enzymes directly control lipid uptake and metabolic remodeling during atherogenesis remains unclear. Methods and Results: Here, transcriptomic profiling identified ubiquitin-specific protease 20 (USP20) as a previously unrecognized regulator of macrophage foam cell formation. Genetic and pharmacological studies demonstrated that USP20 promoted macrophage lipid accumulation and foam cell formation, whereas macrophage-specific Usp20 deficiency markedly attenuated atherosclerotic lesion formation, lipid deposition, and macrophage accumulation in mice. To elucidate the underlying mechanism, integrative analysis of USP20-interacting proteins and proteomic alterations in Usp20-deficient macrophages identified fatty acid-binding protein 5 (FABP5) as a substrate of USP20. Mechanistically, USP20 interacted with FABP5 and stabilized its protein abundance by preventing ubiquitin-dependent proteasomal degradation. Consequently, USP20-mediated stabilization of FABP5 enhanced PPAR{gamma} occupancy at the Cd36 promoter, thereby increasing Cd36 transcription, ox-LDL uptake, and foam cell formation. Accordingly, Fabp5 knockdown abolished USP20-induced CD36 expression, ox-LDL uptake, and foam cell formation, whereas pharmacological activation of PPAR{gamma} restored CD36 expression in Fabp5-deficient macrophages. Finally, macrophage-targeted delivery of the USP20 inhibitor GSK2643943A markedly reduced atherosclerotic burden without evident systemic toxicity, supporting the therapeutic potential of targeting USP20 in atherosclerosis. Conclusions: USP20 promotes macrophage foam cell formation by stabilizing FABP5 and enhancing PPAR{gamma}-dependent Cd36 transcription. Targeting the USP20-FABP5-PPAR{gamma}-CD36 axis may represent a therapeutic strategy to limit macrophage lipid accumulation, metabolic dysfunction, and atherosclerosis progression.