The sodium-glucose co-transporter 2 inhibitor empagliflozin attenuates cardiac fibrosis and improves ventricular hemodynamics in hypertensive heart failure rats

Hsiang-Chun Lee, Yi-Lin Shiou, Shih-Jie Jhuo, Chia-Yuan Chang, Po-Len Liu, Wun-Jyun Jhuang, Zen-Kong Dai, Wei-Yu Chen, Yun-Fang Chen, An-Sheng Lee, Hsiang-Chun Lee, Yi-Lin Shiou, Shih-Jie Jhuo, Chia-Yuan Chang, Po-Len Liu, Wun-Jyun Jhuang, Zen-Kong Dai, Wei-Yu Chen, Yun-Fang Chen, An-Sheng Lee

Abstract

Background: Sodium glucose co-transporter 2 inhibitor (SGLT2i), a new class of anti-diabetic drugs acting on inhibiting glucose resorption by kidneys, is shown beneficial in reduction of heart failure hospitalization and cardiovascular mortality. The mechanisms remain unclear. We hypothesized that SGLT2i, empagliflozin can improve cardiac hemodynamics in non-diabetic hypertensive heart failure.

Methods and results: The hypertensive heart failure model had been created by feeding spontaneous hypertensive rats (SHR) with high fat diet for 32 weeks (total n = 13). Half SHRs were randomized to be administered with SGLT2i, empagliflozin at 20 mg/kg/day for 12 weeks. After evaluation of electrocardiography and echocardiography, invasive hemodynamic study was performed and followed by blood sample collection and tissue analyses. Empagliflozin exhibited cardiac (improved atrial and ventricular remodeling) and renal protection, while plasma glucose level was not affected. Empagliflozin normalized both end-systolic and end-diastolic volume in SHR, in parallel with parameters in echocardiographic evaluation. Empagliflozin also normalized systolic dysfunction, in terms of the reduced maximal velocity of pressure incline and the slope of end-systolic pressure volume relationship in SHR. In histological analysis, empagliflozin significantly attenuated cardiac fibrosis in both atrial and ventricular tissues. The upregulation of atrial and ventricular expression of PPARα, ACADM, natriuretic peptides (NPPA and NPPB), and TNF-α in SHR, was all restored by treatment of empagliflozin.

Conclusions: Empagliflozin improves hemodynamics in our hypertensive heart failure rat model, associated with renal protection, attenuated cardiac fibrosis, and normalization of HF genes. Our results contribute some understanding of the pleiotropic effects of empagliflozin on improving heart function.

Keywords: ACADM; Cardiac fibrosis; Empagliflozin; Heart failure; Hemodynamics; High-fat; Hypertensive; PPARα; SGLT2 inhibitor.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
The animal grouping and time line of the experimental protocol
Fig. 2
Fig. 2
Occurrence of atrial and ventricular premature beats in hypertensive rats. Representative electrocardiographic tracings for normotensive rats (WKY, trace a), hypertensive rats (SHR, traces b, c) and empagliflozin-treated hypertensive rats (EMPA, traces d, e). Premature beats were specifically labeled as APC for an atrial origin, and VPC for a ventricular origin. The number of APC and VPC for each rat (f, g) was calculated from 5 min ECG recording
Fig. 3
Fig. 3
Echocardiographic measurements in normotensive (WKY) and hypertensive rats without (SHR) and with administration of empagliflozin (EMPA). a Representative M-mode tracings for aortic root diameter (Ao), left atrial dimension (LA), and left ventricle (LV) measurements of rats in three groups (total n = 9 for WKY, n = 7 for SHR, n = 7 for EMPA). b–i Plots of echocardiographic measurement results for LA dimension, aorta diameter, end-diastole and end-systole dimensions of left ventricle (LVIDd and LVIDs), end-systole septum thickness (IVSd), LV mass, fraction shortening (FS), and ejection fraction (EF) of LV. **P < 0.01 vs WKY, ***P < 0.001 vs WKY, #P < 0.05 vs WKY
Fig. 4
Fig. 4
Empagliflozin restored HFD-induced systolic dysfunction in SHR rats. a Representative P–V loops at different preloads in WKY, SHR, and EMPA rats. b Comparison of the mean end-systolic volume (Ves), end-diastolic volume (Ved), end-systolic pressure (Pes), and end-diastolic pressure (Ped) in the 3 rat models. c Comparison of the maximal velocity of pressure rise (+ dP/dt) and fall (− dP/dt) in the 3 rat models. d Comparison of the mean arterial elastance. (Ea) and the time constant of isovolumic pressure decay (tau) in the 3 rat models. e Mean slopes of the ESPVR and the EDPVR are shown for the 3 rat models. For the quantitative analyses, n = 5 per group. *P < 0.05, ***P < 0.01 vs WKY rats; #P < 0.05 vs SHR rats
Fig. 5
Fig. 5
Attenuated fibrosis in empagliflozin-treated atria and ventricles. Gross hearts (a), histological sections (b), Masson trichrome staining of atrial tissue (c) and ventricular tissue (shown in cross, longitudinal sections, and peri-vascular sections) (d) of high-fat-fed wild type (WKY), spontaneous hypertensive rats (SHR), and empagliflozin-treated SHR (EMPA). e The numerical data of the heart weight was shown. The quantified fibrosis area shows significant increase in SHR compared to WKY and significant attenuation by EMPA, in both atrial (f *P = 0.0045; #P < 0.0001) and ventricular tissue (g *P < 0.0001; #P = 0.0084; $P = 0.0002)
Fig. 6
Fig. 6
Empagliflozin attenuates hypertension-induced collagen deposition in cardiac fibrosis of left atrial and left ventricular. Collagen fiber deposition and arrangement was demonstrated by second-harmonic generation (SHG) microscopy for left atrial (a) and left ventricular (b) tissue of normo-tensive rats (WKY), spontaneous hypertensive rats (SHR), and empagliflozin-treated SHR (EMPA). All scans are transmural and show the whole myocardial wall (from left to right: endocardium or luminal surface to epicardium or pericardium). Collagen deposition is demonstrated with high SHG intensity
Fig. 7
Fig. 7
Transcriptional modulation by empagliflozin on genes related to fatty acid metabolism (PPARα and ACADM) and natriuretic peptides (NPPA and NPPB), and TNF-α. The transcriptional expression of genes in the atrial tissue (a–e) and in the ventricular tissue (f–j) of control rats (WKY), spontaneous hypertensive rats (SHR), and empagliflozin-treated SHR (EMPA) (n = 4 for each group). Statistical significance is labeled as *for SHR vs WKY; #for EMPA vs SHR; $for EMPA vs WKY

References

    1. Zinman B, Wanner C, Lachin JM, Fitchett D, Bluhmki E, Hantel S, Mattheus M, Devins T, Johansen OE, Woerle HJ, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med. 2015;373(22):2117–2128.
    1. Udell JA, Yuan Z, Rush T, Sicignano NM, Galitz M, Rosenthal N. Cardiovascular outcomes and risks after initiation of a sodium glucose cotransporter 2 inhibitor. Circulation. 2018;137(14):1450–1459.
    1. Bethel MA, McMurray JJV. Class effect for sodium glucose-cotransporter-2 inhibitors in cardiovascular outcomes: implications for the cardiovascular disease specialist. Circulation. 2018;137(12):1218–1220.
    1. Neal B, Perkovic V, Mahaffey KW, de Zeeuw D, Fulcher G, Erondu N, Shaw W, Law G, Desai M, Matthews DR. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med. 2017;377(7):644–657.
    1. Fitchett D, Zinman B, Wanner C, Lachin JM, Hantel S, Salsali A, Johansen OE, Woerle HJ, Broedl UC, Inzucchi SE, et al. Heart failure outcomes with empagliflozin in patients with type 2 diabetes at high cardiovascular risk: results of the EMPA-REG OUTCOME(R) trial. Eur Heart J. 2016;37(19):1526–1534.
    1. Sano M. A new class of drugs for heart failure: SGLT2 inhibitors reduce sympathetic overactivity. J Cardiol. 2018;71(5):471–476.
    1. Pabel S, Wagner S, Bollenberg H, Bengel P, Kovacs A, Schach C, Tirilomis P, Mustroph J, Renner A, Gummert J, et al. Empagliflozin directly improves diastolic function in human heart failure. Eur J Heart Fail. 2018;20(12):1690–1700.
    1. Lahnwong S, Chattipakorn SC, Chattipakorn N. Potential mechanisms responsible for cardioprotective effects of sodium–glucose co-transporter 2 inhibitors. Cardiovasc Diabetol. 2018;17(1):101.
    1. Vettor R, Inzucchi SE, Fioretto P. The cardiovascular benefits of empagliflozin: sGLT2-dependent and -independent effects. Diabetologia. 2017;60(3):395–398.
    1. Cefalu WT. Paradoxical insights into whole body metabolic adaptations following SGLT2 inhibition. J Clin Investig. 2014;124(2):485–487.
    1. Tikkanen I, Narko K, Zeller C, Green A, Salsali A, Broedl UC, Woerle HJ, Investigators E-RB Empagliflozin reduces blood pressure in patients with type 2 diabetes and hypertension. Diabetes Care. 2015;38(3):420–428.
    1. Zhou H, Wang S, Zhu P, Hu S, Chen Y, Ren J. Empagliflozin rescues diabetic myocardial microvascular injury via AMPK-mediated inhibition of mitochondrial fission. Redox Biol. 2018;15:335–346.
    1. Mustroph J, Wagemann O, Lucht CM, Trum M, Hammer KP, Sag CM, Lebek S, Tarnowski D, Reinders J, Perbellini F, et al. Empagliflozin reduces Ca/calmodulin-dependent kinase II activity in isolated ventricular cardiomyocytes. ESC Heart Fail. 2018;5(4):642–648.
    1. Shiou YL, Huang IC, Lin HT, Lee HC. High fat diet aggravates atrial and ventricular remodeling of hypertensive heart disease in aging rats. J Formosan Med Assoc. 2018;117(7):621–631.
    1. Ge F, Hu C, Hyodo E, Arai K, Zhou S, Lobdell H, Walewski JL, Homma S, Berk PD. Cardiomyocyte triglyceride accumulation and reduced ventricular function in mice with obesity reflect increased long chain fatty acid uptake and de novo fatty acid synthesis. J Obes. 2012;2012:205648.
    1. Kmecova J, Klimas J. Heart rate correction of the QT duration in rats. Eur J Pharmacol. 2010;641(2):187–192.
    1. Chang KC, Lee AS, Chen WY, Lin YN, Hsu JF, Chan HC, Chang CM, Chang SS, Pan CC, Sawamura T, et al. Increased LDL electronegativity in chronic kidney disease disrupts calcium homeostasis resulting in cardiac dysfunction. J Mol Cell Cardiol. 2015;84:36–44.
    1. Johnson RN, Metcalf PA, Baker JR. Fructosamine: a new approach to the estimation of serum glycosylprotein. An index of diabetic control. Clinica Chimica Acta. 1983;127(1):87–95.
    1. Finck BN. The PPAR regulatory system in cardiac physiology and disease. Cardiovasc Res. 2007;73:269.
    1. Kurtz DM, Tian L, Gower BA, Nagy TR, Pinkert CA, Wood PA. Transgenic studies of fatty acid oxidation gene expression in nonobese diabetic mice. J Lipid Res. 2000;41(12):2063–2070.
    1. Sivasubramanian N, Coker ML, Kurrelmeyer KM, MacLellan WR, DeMayo FJ, Spinale FG, Mann DL. Left ventricular remodeling in transgenic mice with cardiac restricted overexpression of tumor necrosis factor. Circulation. 2001;104(7):826–831.
    1. Sergeeva IA, Christoffels VM. Regulation of expression of atrial and brain natriuretic peptide, biomarkers for heart development and disease. Biochim Biophys Acta. 2013;1832(12):2403–2413.
    1. Kusaka H, Koibuchi N, Hasegawa Y, Ogawa H, Kim-Mitsuyama S. Empagliflozin lessened cardiac injury and reduced visceral adipocyte hypertrophy in prediabetic rats with metabolic syndrome. Cardiovasc Diabetol. 2016;15(1):157.
    1. Majane OH, Vengethasamy L, du Toit EF, Makaula S, Woodiwiss AJ, Norton GR. Dietary-induced obesity hastens the progression from concentric cardiac hypertrophy to pump dysfunction in spontaneously hypertensive rats. Hypertension. 2009;54(6):1376–1383.
    1. Habibi J, Aroor AR, Sowers JR, Jia G, Hayden MR, Garro M, Barron B, Mayoux E, Rector RS, Whaley-Connell A, et al. Sodium glucose transporter 2 (SGLT2) inhibition with empagliflozin improves cardiac diastolic function in a female rodent model of diabetes. Cardiovasc Diabetol. 2017;16(1):9.
    1. Lee T-M, Chang N-C, Lin S-Z. Dapagliflozin, a selective SGLT2 inhibitor, attenuated cardiac fibrosis by regulating the macrophage polarization via STAT3 signaling in infarcted rat hearts. Free Radical Biol Med. 2017;104:298–310.
    1. Ojima A, Matsui T, Nishino Y, Nakamura N, Yamagishi S. Empagliflozin, an inhibitor of sodium-glucose cotransporter 2 exerts anti-inflammatory and antifibrotic effects on experimental diabetic nephropathy partly by suppressing AGES-receptor axis. Hormone Metabol Res. 2015;47(9):686–692.
    1. MacIsaac RJ, Jerums G, Ekinci EI. Cardio-renal protection with empagliflozin. Ann Transl Med. 2016;4(20):409.
    1. Packer M. Do sodium–glucose co-transporter-2 inhibitors prevent heart failure with a preserved ejection fraction by counterbalancing the effects of leptin? A novel hypothesis. Diabetes Obes Metab. 2018;20(6):1361–1366.
    1. Tanajak P, Sa-Nguanmoo P, Sivasinprasasn S, Thummasorn S, Siri-Angkul N, Chattipakorn SC, Chattipakorn N. Cardioprotection of dapagliflozin and vildagliptin in rats with cardiac ischemia–reperfusion injury. J Endocrinol. 2018;236(2):69–84.
    1. Schannwell CM, Schneppenheim M, Perings S, Plehn G, Strauer BE. Left ventricular diastolic dysfunction as an early manifestation of diabetic cardiomyopathy. Cardiology. 2002;98(1–2):33–39.
    1. Hammoudi N, Jeong D, Singh R, Farhat A, Komajda M, Mayoux E, Hajjar R, Lebeche D. Empagliflozin improves left ventricular diastolic dysfunction in a genetic model of type 2 diabetes. Cardiovasc Drugs Ther. 2017;31(3):233–246.
    1. Al-Jobori H, Daniele G, Cersosimo E, Triplitt C, Mehta R, Norton L, DeFronzo RA, Abdul-Ghani M. Empagliflozin and kinetics of renal glucose transport in healthy individuals and individuals with type 2 diabetes. Diabetes. 2017;66(7):1999–2006.
    1. McMurray J. EMPA-REG—the “diuretic hypothesis”. J Diabetes Compl. 2016;30(1):3–4.
    1. Mudaliar S, Alloju S, Henry RR. Can a shift in fuel energetics explain the beneficial cardiorenal outcomes in the EMPA-REG OUTCOME study? A unifying hypothesis. Diabetes care. 2016;39(7):1115–1122.
    1. Ferrannini E, Mark M, Mayoux E. CV protection in the EMPA-REG OUTCOME trial: a “Thrifty Substrate” hypothesis. Diabetes Care. 2016;39(7):1108–1114.
    1. Inzucchi SE, Zinman B, Fitchett D, Wanner C, Ferrannini E, Schumacher M, Schmoor C, Ohneberg K, Johansen OE, George JT, et al. How does empagliflozin reduce cardiovascular mortality? Insights from a mediation analysis of the EMPA-REG OUTCOME trial. Diabetes Care. 2018;41(2):356–363.
    1. Perrone-Filardi P, Avogaro A, Bonora E, Colivicchi F, Fioretto P, Maggioni AP, Sesti G, Ferrannini E. Mechanisms linking empagliflozin to cardiovascular and renal protection. Int J Cardiol. 2017;241:450–456.
    1. Zhou Y, Wu W. The sodium–glucose co-transporter 2 inhibitor, empagliflozin, protects against diabetic cardiomyopathy by inhibition of the endoplasmic reticulum stress pathway. Cell Physiol Biochem. 2017;41(6):2503–2512.
    1. Bertero E, Prates Roma L, Ameri P, Maack C. Cardiac effects of SGLT2 inhibitors: the sodium hypothesis. Cardiovasc Res. 2018;114(1):12–18.
    1. Baartscheer A, Schumacher CA, Wust RC, Fiolet JW, Stienen GJ, Coronel R, Zuurbier CJ. Empagliflozin decreases myocardial cytoplasmic Na+ through inhibition of the cardiac Na+/H+ exchanger in rats and rabbits. Diabetologia. 2017;60(3):568–573.
    1. Andreadou I, Efentakis P, Balafas E, Togliatto G, Davos CH, Varela A, Dimitriou CA, Nikolaou PE, Maratou E, Lambadiari V, et al. Empagliflozin limits myocardial infarction in vivo and cell death in vitro: role of STAT3, mitochondria, and redox aspects. Front Physiol. 2017;8:1077.
    1. Solini A, Giannini L, Seghieri M, Vitolo E, Taddei S, Ghiadoni L, Bruno RM. Dapagliflozin acutely improves endothelial dysfunction, reduces aortic stiffness and renal resistive index in type 2 diabetic patients: a pilot study. Cardiovasc Diabetol. 2017;16(1):138.
    1. Aroor AR, Das NA, Carpenter AJ, Habibi J, Jia G, Ramirez-Perez FI, Martinez-Lemus L, Manrique-Acevedo CM, Hayden MR, Duta C, et al. Glycemic control by the SGLT2 inhibitor empagliflozin decreases aortic stiffness, renal resistivity index and kidney injury. Cardiovasc Diabetol. 2018;17(1):108.
    1. Matsutani D, Sakamoto M, Kayama Y, Takeda N, Horiuchi R, Utsunomiya K. Effect of canagliflozin on left ventricular diastolic function in patients with type 2 diabetes. Cardiovasc Diabetol. 2018;17(1):73.

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