With the introduction of antiretroviral therapy (ART), human immunodeficiency virus (HIV) has progressed to a chronic inflammatory disease with accelerated, subclinical end-organ damage, specifically cardiovascular disease (CVD). People with HIV (PWH) have higher incidence, risk, and mortality from CVD, such as atherosclerosis, diastolic dysfunction, and heart failure. Several recent clinical reports have shown that PWH have a predisposition to developing heart failure with preserved ejection fraction (HFpEF), presenting with pathological concentric hypertrophy, diffuse fibrosis, and diastolic dysfunction. As such, an investigation into immunological and molecular mechanisms promoting pathological changes in the heart is necessary. Recent clinical reports show that people living with HFpEF have elevated plasma osteopontin (Opn), and plasma Opn is a powerful predictor of HFpEF severity, HFpEF-related hospitalizations, and mortality. Second, several animal models of HFpEF phenotypes have suggested Opn is involved in driving or perpetuating diastolic dysfunction and cardiac fibrosis. Therefore, we investigated changes in Opn in a cohort of PWH and two translationally relevant models of HIV infection (non-human primates and humanized mice) to identify the pathological role of Opn in cardiac fibrosis and detail the adjunctive potential of Opn for PWH presenting with HFpEF. In Chapter 2, twenty asymptomatic, antiretroviral-treated women with HIV (WHIV) and fourteen women without HIV (HIV-women) matched on age and body mass index underwent cardiac magnetic resonance imaging (MRI) and immune phenotyping. First, we compared a number of immunological parameters to the extensive cardiac MRI parameters in WHIV. Secondly, we analyzed relationships between plasma Opn with cardiac structure and function and markers of immune activation among WHIV, HIV- women, and the whole cohort. Multivariable modeling among the whole group was performed using myocardial fibrosis and myocardial steatosis, respectively, as the dependent variable and HIV status, atherosclerotic cardiovascular disease (ASCVD) risk score, and plasma Opn as independent variables. Among WHIV, multi-variable modeling was performed using plasma Opn as the dependent variable and CD4+ T cell count, HIV viral load, and the respective immune parameter, relating to plasma OPN in bivariate analyses, as an independent variable. In Chapter 3, we investigated bulk transcriptomic changes in the left ventricle of the heart in a model of HIV infection. We utilize the highly translatable simian immunodeficiency virus (SIV)-infected rhesus macaque model to identify changes in the myocardium with and without ART. Animals were selected by viral load, with SIV-infected animals having a high titer of plasma viral load and the SIV-infected animals with ART having a reduction in viral load by several logs. We performed total RNA-Seq on left ventricle tissue from uninfected animals, SIV-infected animals, and SIV-infected animals receiving a clinically relevant ART regimen. SIV infection led to high plasma viral load, but little to no SIV RNA was detectable in the left ventricle, shown by minimal of SIV RNA+ cells in the heart and no SIV sequences identified from RNA-Seq. SIV infection produced a highly inflammatory reaction in the heart, predominated by interferon and pathogen response. Additionally, interferon gamma (IFNg) and lipopolysaccharide (LPS) were both identified as potential upstream drivers of transcriptomic changes in the heart from SIV infection. Reduction of viral load by ART reduced the interferon and cytokine response in the heart; however, SIV-infected animals receiving ART exhibited decreased expression of integral genes directly involved in fatty acid (FA) metabolism, carnitine shuttling, and beta-oxidation. In Chapter 4, we use both in vitro and in vivo modeling to identify molecular mechanisms involved in the development of cardiac fibrosis. We utilized mouse embryonic fibroblasts (MEFs) modeled cardiac fibroblasts and were stimulated with IFNg, LPS, and TGF-b for phenotypic changes in contraction and cytokine production. The interplay of Opn and cardiac fibrosis was investigated in SIV-infected macaques with/without ART and HIVinfected humanized mice with/without an Opn-inhibiting RNA aptamer. LPS-stimulated MEFs retained myofibroblast-like contractility from TGF-b stimulation, secreted inflammatory cytokines/chemokines, and produced Opn (Spp1 transcripts). SIV-infected animals had elevated plasma Opn at necropsy, accumulation of full-length Opn in the ventricle, and ventricular interstitial fibrosis. Multivariate regression identified growth differentiation factor (GDF)-15, inflammatory CD14+CD16+ monocytes, and CD163 expression on CD14+ CD16+ monocytes as independent predictors of plasma Opn during SIV infection. HIV-infected humanized mice showed increased interstitial fibrosis compared to uninfected/untreated animals, and systemic inhibition of Opn by RNA aptamer reduced left ventricle fibrosis in HIV-infected humanized mice. These studies combined a clinical cohort of WHIV, SIV-infected rhesus macaques, and HIV-infected humanized mice to determine the role of Opn in the pathophysiology of cardiac deficits from HIV infection. Our primary goals were to begin to unravel the role of Opn in the development of HFpEF phenotypes seen in PWH, detail Opn as a converging biomarker of cardiac stress and remodeling and immune dysfunction in HIV infection, and investigate the therapeutic potential of Opn to reduce cardiac fibrosis from HIV infection. While Opn has a broad spectrum of physiological and pathological functions, we aimed to frame Opn as an important protein of interest in future studies into HFpEF in PWH. / Biomedical Sciences

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Background: A major problem in the treatment of human hypertension is the late diagnosis of hypertension and, hence, the delayed start of treatment. Very often, hypertension has existed for a long time and cardiac damage has already developed. Therefore, we tested whether late- onset antihypertensive treatment is effective in lowering blood pressure (BP) and in reducing or even preventing left ventricular hypertrophy and fibrosis. Methods: Twenty-one male 60-week-old spontaneously hypertensive rats (SHR) were included. Fourteen rats received oral treatment with captopril (CAP) either as monotherapy or combined with nifedipine (CAP + NIF) over 22 weeks. Seven untreated SHR served as controls. We examined the therapeutic effects on BP, heart weight and histological and biochemical markers of left ventricular remodeling and fibrosis. Results: At 82 weeks of age, BP was reduced in the CAP and CAP + NIF groups by 44 and 51 mmHg, respectively (p < 0.001), but not in untreated controls. Despite the late therapy start, cardiac hypertrophy and fibrosis were attenuated compared to controls. Both treatments reduced heart weight by 1.2 mg/g (25%, p = 0.001) and collagens I and III by 66% and 60%, respectively (p < 0.001), thus proving nearly equivalent cardioprotective efficacy. Conclusion: These data clearly emphasize the benefit of antihypertensive treatment in reducing BP and mitigating the development of cardiac amage even when treatment is started late in life.

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La fibrose cardiaque fait le lit des arythmies cardiaques, qu’elles soient atriales ou ventriculaires. L’IRM est devenue un outil non invasif indispensable pour diagnostiquer la présence de fibrose au niveau cardiaque, mais offre également des informations pronostiques, ainsi que pour le suivi des patients atteints de fibrillation auriculaire (FA), notamment persistante. La technique de référence reste le rehaussement tardif après injection de gadolinium, permettant de révéler des régions localisées de fibrose. Notre travail a consisté en la mise au point d’une technique non invasive (par la mesure du T2 avec IRM à haut champ à 11,75 T) afin de quantifier la fibrose myocardique interstitielle diffuse dans un modèle de souris diabétiques. La fibrose a été significativement corrélée à une survenue plus importante des arythmies ventriculaires en comparaison avec un groupe de souris contrôles. L’étape suivante a été de transposer cette technique de mesure de T2 en IRM clinique chez des patients devant bénéficier d’une procédure d’ablation de FA. La deuxième technique, cette fois-ci invasive pour évaluer la fibrose (notamment atriale) pour les patients atteints de FA est la cartographie de voltage au niveau de l’oreillette gauche. Nous avons utilisé un nouveau système de cartographie à ultra-haute définition afin de quantifier la fibrose (zones cicatricielles denses) correspondant aux régions dont les signaux enregistrés avaient une amplitude bipolaire inférieure à 0,015 mV, soit très en deçà des seuils précédemment rapportés concernant la fibrose. / Fibrosis represents the main substrate for cardiac arrhythmias, either atrial or ventricular. MRI has become a critical tool to not only diagnose the presence of cardiac fibrosis, but also provides important informations on the prognosis and the follow-up of patients with atrial fibrillation (AF), especially in its persistent type. The gold standard is the Late Gadolinium Enhancement, allowing to reveal localized regions of fibrosis. Our study reported a technique for non invasive quantification of interstitial diffuse ventricular fibrosis in diabetic mice (T2 measurement high field MRI at 11,75 T). This fibrosis was significantly correlated to the occurrence of ventricular arrhythmias in comparison with the control group. The next step was the transposition of this T2 measurement with MRI in the clinical setup of patients who undergo an AF ablation procedure. The second technique for atrial fibrosis assessment for patients suffering from AF is the invasive realization of left atrial voltage mapping. A new ultra-high definition system was used to quantify the fibrosis (dense scar) in regions with bipolar amplitude electrograms of less than 0,015 mV. This cutoff was far lower than the previously published definition of the dense scar in the literature (< 0,1 mV).

Abstract The increase of cardiac hemodynamic load that requires increased mechanical performance drives adaptation of the heart to maintain cardiac function. Modification of protein synthesis in cardiomyocytes allows the cells to adapt to the increased load. Cardiomyocyte hypertrophy and activation of cardiac fibroblasts over the long term is maladaptive and leads to heart failure (HF). Members of the transforming growth factor-&#946; (TGF-&#946;) superfamily contribute to the remodeling process. TGF-β1 acts as a paracrine messenger between cardiomyocytes and cardiac fibroblasts. Connective tissue growth factor (CTGF) modulates TGF-&#946; signaling and plays a role in the development of fibrosis. In the current study, we aimed to investigate whether blocking the actions of CTGF could alleviate ischemic injury and reduce cardiac remodeling. We determined whether blocking the action of these ligands would modulate cardiac hypertrophy and fibrosis. In the first study, we found that antagonizing the function of CTGF protected from transverse aortic constriction (TAC) -induced left ventricular remodeling. In the second study in myocardial infarction (MI) model, blocking the function of CTGF resulted in improved post-MI survival and this prevented to the decrease in left ventricular contractile function as compared to the situation in control mice. Treatment with CTGF mAb attenuated the development of dilated cardiomyopathy and limited the increase in cardiomyocyte size and deposition of interstitial fibrosis in a remote area. In the third study, targeting the TGF-&#946; superfamily members myostatin and activins, by administration of a soluble decoy receptor of activin receptor 2B (ACVR2B-Fc) did not affect the extent of MI injury or cardiac remodeling in MI -induced ischemic HF. Understanding the complex and converging pathways regulating cardiac remodeling is a major challenge, but it may allow for opportunities to develop new therapies, new medicines and provide new hope for people with these life-threatening diseases. / Tiivistelmä Sydämen lisääntynyt kuormitus vaatii lisääntynyttä supistusvoimaa, joka johtaa sydänlihaksen adaptaatioon pumppaustehon ylläpitämiseksi. Alkuvaiheessa sydämen liikakasvu on hyödyllistä, mutta pidempään jatkuessaan se johtaa lopulta pumppaustoiminnan heikkenemiseen ja sydämen vajaatoimintaan. Useiden signalointimekanismien on osoitettu säätelevän sydänlihaksen adaptoitumista patologisille tiloille. Transformoiva kasvutekijä –&#946; (TGF-&#946;) proteiiniperhe säätelee sydämen adaptoitumista sekä vasemman kammion seinämän myötäävyyttä venytykselle. TGF-&#946;1 indusoi supistuskykyisten myofibroblastien muodostumista sekä kollageenin tuotantoa. Runsas kollageenin tuotanto vahvistaa sydämen seinämää ja on tarpeen sydäninfarktivaurion korjaamisessa, mutta pitkään jatkuessaan se heikentää sydämen toimintaa ja altistaa rytmihäiriöille, sydämen vajaatoiminnalle sekä sydänperäiselle äkkikuolemalle. Sidekudoskasvutekijä (CTGF) säätelee TGF-&#946;1:n signalointia ja se osallistuu haavan paranemiseen sekä fibroosiin. Tutkimuksessa selvitettiin, voidaanko sidekudoskasvutekijän tai TGF-&#946; -perheen proteiinien toimintaa estämällä lievittää sydämen vajaatoiminnan kehittymistä. Koetuloksemme osoittavat, että CTGF:n toiminnan estäminen vasta-aineen (mAb) avulla vähentää hemodynaamisen liikakuormituksen indusoimaa vasemman kammion toiminnan heikkenemistä, kammion laajenemista sekä fibroosia. CTGF mAb myös vähentää kuolleisuutta ja estää sydämen toiminnan heikkenemistä sydäninfarktin jälkeen sekä lievittää sydäninfarktin jälkeistä dilatoivan kardiomyopatian kehittymistä. Aktiviinien ja myostatiinin toiminnan esto liukoisen aktiviinireseptori 2B:n (ACVR2B-Fc) avulla sen sijaan ei vaikuta sydäninfarktivaurioon tai iskeemisen vajaatoiminnan kehittymiseen. ACVR2B-Fc kuitenkin lisää luurankolihaksen kasvua, estäen sydämen vajaatoimintaan liittyvää luurankolihaskatoa. Sydämen hypertrofian ja vajaatoiminnan syntymisen kannalta keskeisten signaalinvälitysreittien tunnistaminen ja niiden toiminnan ymmärtäminen auttaisi kehittämään tehokkaampia lääkehoitoja sydänsairauksiin.

Background: Fibulin-1, an extracellular matrix component and mediator in cardiac fibrosis, is expressed in cardiac valves, heart muscles and blood vessels and may contribute to different cardiovascular pathological conditions such as hypertension, aortic valve stenosis, atrial fibrillation and coronary artery disease. The most conspicuous functions of fibulin-1 include cell adhesion and cell migration within the extracellular matrix (ECM). This was found to reflect vascular dysfunction contributing to the development of fibrosis in the myocardium by means of changes in the ECM, possibly as a result of inflammation. Inflammatory mediators such as C-reactive protein (CRP) and albumin have been investigated over the years for the role they play in the inflammatory processes. However, one inflammatory mediator, soluble urokinase-type plasminogen activator receptor (suPAR), only emerged as a potential biomarker in the development of sclerotic disease. SuPAR is a soluble bioactive form of the urokinase-type plasminogen activator receptor (uPAR) secreted by inflammatory cells such as macrophages, endothelial cells and monocytes. The most profound functions of suPAR such as cell migration and cell adhesion contribute to the development of diseases such as infection, autoimmune diseases, cancer and atherosclerosis. Motivation and aim: This study was motivated by an awareness of the limited data on the potential link between fibulin-1 and suPAR, along with other markers of inflammation (CRP and albumin). We aimed to compare the levels of a marker of cardiac fibrosis (fibulin-1) and inflammatory mediators (suPAR, CRP and albumin) in African and Caucasian men and women. A second aim was to explore fibulin-1 and its potential association with these inflammatory markers independent of haemodynamic and metabolic risk factors in a bi-ethnic cohort from South Africa. Methodology: Data from the cross-sectional SAfrEIC study (South African study regarding the role of Sex, Age and Ethnicity on Insulin sensitivity and Cardiovascular function) were used, which initially included 756 participants. Our study population comprised 290 Africans (men: n=130; women: n=160) and 343 Caucasians (men: n=160; women: n=183). We excluded HIV-infected participants (n=115) as well as those with missing data (n=8). Traditional cardiovascular measurements together with the relevant biochemical analyses were done. T-tests and Chi-square tests were used to compare means and proportions between groups, respectively. Single and partial correlations were performed to determine the relationship of fibulin-1 with suPAR, CRP and albumin, with adjustments for age. SuPAR, CRP and albumin were divided into tertiles to explore the association with fibulin-1 levels, while adjusting for age, body mass index (BMI) and diastolic blood pressure (DBP) by using analysis of covariance (ANCOVA). Multiple regression analysis was performed to explore independent associations. Results: Participants were divided into African and Caucasian men and women due to significant interactions of the main effects of ethnicity and gender on the association of fibulin-1 with suPAR (ethnicity: F(633)=7.29; p<0.001 and gender: F(633)=7.99; p<0.001). Fibulin-1 levels were higher in African men (p=0.010), whereas CRP was higher in African women (p<0.001) compared to their Caucasian counterparts. In both gender groups suPAR levels were higher and albumin lower in Africans compared to Caucasians (p<0.006). In single regression analyses, a positive correlation existed between fibulin-1 and suPAR in African (r=0.19; p=0.028) and Caucasian men (r=0.37; p<0.001), also in African (r=0.193; p=0.028) and Caucasian women (r=0.14; p=0.036). After adjustments were applied for age, this correlation remained in African (r=0.23; p=0.010) and Caucasian men (r=0.22; p=0.005) only. An inverse correlation was found between fibulin-1 and albumin in African men (r=-0.28; p=0.002), but not in Caucasian men (r=-0.09; p=0.245). No significant correlation was found between fibulin-1 and CRP in any group. Forward stepwise regression analysis was performed in men and the previous associations between fibulin-1 and suPAR were confirmed in African and Caucasian men; along with the inverse relationship of fibulin-1 with albumin (Adj. R2=0.217; β=–0.210; p=0.013) in African men only. Conclusion: Fibulin-1 was positively associated with suPAR in African and Caucasian men, but not in women. We also found fibulin-1 to be negatively associated with albumin in African men only. These results are indicative of the presence of potential subclinical low-grade inflammation as depicted by suPAR within the extracellular matrix. This low-grade inflammation may contribute to the potential onset of cardiac fibrosis or vascular sclerosis among these South African men with lower albumin levels. / MSc (Physiology), North-West University, Potchefstroom Campus, 2014