Metformin Confers Cardiac and Renal Protection in Sudden Cardiac Arrest via AMPK Activation

Cardiac arrest (CA) causes high mortality due to multi-system organ damage attributable to ischemia-reperfusion injury. Recent work in our group found that among diabetic patients who experienced cardiac arrest, those taking metformin had less evidence of cardiac and renal damage after cardiac arrest when compared to those not taking metformin. To investigate the potential for metformin to impact cardiac arrest outcomes, the current study investigates metformin interventions on cardiac and renal outcomes in a non-diabetic CA mouse model. We found that two weeks of metformin pretreatment protects against reduced ejection fraction and reduces kidney ischemia-reperfusion injury at 24 hours post-arrest. This cardiac and renal protection depends on AMPK signaling, as demonstrated by outcomes in mice pretreated with the AMPK activator AICAR or metformin plus the AMPK inhibitor compound C. At this 24-hour time point, gene expression analysis showed that metformin pretreatment caused changes supporting autophagy, antioxidant response, and protein translation. Further investigation found associated improvements in mitochondrial structure and markers of autophagy. We also found that markers of protein nitrosylation between sham and arrest were not significantly different and thus unlikely to be a driver of gene expression differences. Notably, Western analysis indicated that protein synthesis was preserved in arrest hearts of animals pretreated with metformin. The AMPK activation-mediated protection of protein synthesis was also demonstrated in a hypoxia/reoxygenation cell culture model. Despite the positive impacts of pretreatment in vivo and in vitro, metformin did not preserve ejection fraction when deployed at resuscitation. Taken together, we propose that metformins in vivo cardiac preservation occurs through AMPK activation, requires adaptation before arrest, and is associated with preserved protein translation. New and NoteworthyWe leveraged a mouse model of cardiac arrest to study whether metformin pretreatment could protect cardiac function after arrest. We find that AMPK activity is crucial to this protection and characterize several pathways associated with this response. Signaling nodes with strong association may be precise targets to promote cardiac function in ischemia/reperfusion injury or in cardiac stunning.