Metabolic heart disease (MHD) caused by obesity or diabetes is characterized by cardiac hypertrophy, diastolic dysfunction, and fibrosis - a maladaptive remodeling of the extracellular matrix. Though the influence of cardiac fibrosis on the left ventricular diastolic dysfunction has been reported, little is known about the cardiac-specific secreted autocrine, paracrine, or endocrine factors termed "cardiokines" in MHD. Transforming growth factor beta (TGF-b1) is a well-known inducer of cardiac fibrosis. However, the role TGF-b2 in mediating cardiac fibrosis has yet to be described. In addition, follistatin-like 3 (FSTL3), an extracellular inhibitor of activin A and myostatin, is found to be elevated in end-stage heart failure patients and obese individuals. FSTL3 has been suggested as a cardiokine, yet its role in MHD has not been established. To identify cardiokines induced by MHD, two relevant mouse models were employed in this study: the high-fat high sucrose (HFHS) diet feeding model and the cardiomyocyte-specific Fatp1 overexpressing transgenic mouse model. Interstitial fibrosis was observed in both models, accompanied by fibrotic gene expression and anti-fibrotic miR-29 suppression. It was found that Tgf-b1 and Tgf-b2 mRNA were upregulated by 85% and 76%, respectively, in the non-myocytes of 1-month HFHS-fed mice, while Fstl3 was increased by 30% in the myocytes. In contrast, in the FATP1 transgenic animals, Tgf-b2 and Fstl3 were elevated by 3.8-fold and 1.9-fold in the myocytes while Tgf-b1 remained unchanged compared to control animals. The in vitro results tested in NIH3T3 and primary fibroblast cultures indicate that both TGF-b1 and TGF-b2 exerted profibrotic effects via activation of SMAD proteins and collagen synthesis, but FSTL3 did not. Plasma samples collected from patients with metabolic syndrome showed increased FSTL3 levels with strong correlations with cardiac hypertrophy and impaired diastolic function. Overall, this study has demonstrated that TGF-b1 and TGF-b2 are the key profibrotic cardiokines induced in MHD. The study has also revealed the role of FSTL3 as a biomarker for LV hypertrophy induced in MHD. The results presented here should facilitate the development of better diagnosis and treatment for this disease in the future.

Sodium-Glucose Linked Transporter 2 (SGLT2) inhibitors block renal glucose reabsorption and have shown marked cardiac protection in type 2 diabetics, and surprisingly, also in non-diabetics. However, the mechanism by which these drugs improve cardiovascular outcomes is unknown. Metabolic heart disease, which is characterized by cardiac hypertrophy and diastolic dysfunction, is associated with obesity and insulin resistance and leads to adverse cardiovascular outcomes including heart failure with a preserved ejection fraction. A high fat, high sucrose “Western” diet can induce metabolic syndrome, an aggregate of obesity-driven clinical phenotypes including insulin resistance, elevated triglycerides, hypertension, and abnormal cholesterol. Using a mouse model of metabolic syndrome and adult rat ventricular myocytes (ARVMs) in vitro, we aim to determine if the SGLT2 inhibitor Ertugliflozin (ERTU) can prevent metabolic syndrome-induced cardiac pathophysiology and whether ERTU can exert a direct action on cardiomyocytes, a cell type lacking SGLT2. SGLT2 inhibitors have been proposed to act directly on the Sodium-Hydrogen Exchanger 1 (NHE1) and thus could have direct action on cardiomyocytes that may mediate cardioprotective effects. Mice were fed either a control diet (CD) or a high fat high sucrose (HFHS) diet ± ERTU for 16 weeks. Echocardiography was performed and heart weights were obtained. ARVMs were used to assess ERTU’s effect on insulin sensitivity in vitro in a high-palmitate, insulin resistance model, and to test the efficacy of the known NHE1 inhibitor Cariporide (NHEi). A NHE1 activity ammonium chloride pulse assay was performed in HEK293 cells over-expressing either wild-type (WT) or a known NHEi-insensitive point mutant NHE1 ± NHEi or ERTU. In HFHS-fed mice, ERTU attenuated weight gain and restored blood glucose, insulin, hemoglobin A1c, and HOMA-IR to CD levels. HFHS-induced cardiac hypertrophy and diastolic dysfunction were prevented with ERTU. In vitro, high palmitate media decreased insulin stimulated AKT signaling compared to low palmitate media and was rescued by either ERTU or NHEi treatment. ERTU inhibited WT NHE1 activity in HEK293 cells by 67%, whereas activity of the NHEi-insensitive mutant NHE1 was unaffected by ERTU treatment. ERTU prevented the hallmarks of diet-induced metabolic heart disease (cardiac hypertrophy and diastolic dysfunction) in mice. These benefits exceed the expected consequences of glucose control alone. The actions of ERTU on ARVMs in vitro suggest the favorable effects on cardiac structure and function may be due, at least in part, to the direct action of the drug on cardiomyocytes. Furthermore, mutational overexpression studies show that ERTU can directly affect NHE1 in cardiac myocytes. Taken together, this thesis provides evidence that the direct cardioprotective effects of ERTU could be via inhibition of NHE1, a critical modulator of intracellular pH and sodium in the cardiomyocyte, with known implications in the pathophysiology of diabetes and heart failure. / 2022-06-04T00:00:00Z