Sex differences in circulating proteins in heart failure with preserved ejection fraction

Susan Stienen, João Pedro Ferreira, Masatake Kobayashi, Gregoire Preud'homme, Daniela Dobre, Jean-Loup Machu, Kevin Duarte, Emmanuel Bresso, Marie-Dominique Devignes, Natalia López Andrés, Nicolas Girerd, Svend Aakhus, Giuseppe Ambrosio, Hans-Peter Brunner-La Rocca, Ricardo Fontes-Carvalho, Alan G Fraser, Loek van Heerebeek, Gilles de Keulenaer, Paolo Marino, Kenneth McDonald, Alexandre Mebazaa, Zoltàn Papp, Riccardo Raddino, Carsten Tschöpe, Walter J Paulus, Faiez Zannad, Patrick Rossignol, Susan Stienen, João Pedro Ferreira, Masatake Kobayashi, Gregoire Preud'homme, Daniela Dobre, Jean-Loup Machu, Kevin Duarte, Emmanuel Bresso, Marie-Dominique Devignes, Natalia López Andrés, Nicolas Girerd, Svend Aakhus, Giuseppe Ambrosio, Hans-Peter Brunner-La Rocca, Ricardo Fontes-Carvalho, Alan G Fraser, Loek van Heerebeek, Gilles de Keulenaer, Paolo Marino, Kenneth McDonald, Alexandre Mebazaa, Zoltàn Papp, Riccardo Raddino, Carsten Tschöpe, Walter J Paulus, Faiez Zannad, Patrick Rossignol

Abstract

Background: Many patients with heart failure with preserved ejection fraction (HFpEF) are women. Exploring mechanisms underlying the sex differences may improve our understanding of the pathophysiology of HFpEF. Studies focusing on sex differences in circulating proteins in HFpEF patients are scarce.

Methods: A total of 415 proteins were analyzed in 392 HFpEF patients included in The Metabolic Road to Diastolic Heart Failure: Diastolic Heart Failure study (MEDIA-DHF). Sex differences in these proteins were assessed using adjusted logistic regression analyses. The associations between candidate proteins and cardiovascular (CV) death or CV hospitalization (with sex interaction) were assessed using Cox regression models.

Results: We found 9 proteins to be differentially expressed between female and male patients. Women expressed more LPL and PLIN1, which are markers of lipid metabolism; more LHB, IGFBP3, and IL1RL2 as markers of transcriptional regulation; and more Ep-CAM as marker of hemostasis. Women expressed less MMP-3, which is a marker associated with extracellular matrix organization; less NRP1, which is associated with developmental processes; and less ACE2, which is related to metabolism. Sex was not associated with the study outcomes (adj. HR 1.48, 95% CI 0.83-2.63), p = 0.18.

Conclusion: In chronic HFpEF, assessing sex differences in a wide range of circulating proteins led to the identification of 9 proteins that were differentially expressed between female and male patients. These findings may help further investigations into potential pathophysiological processes contributing to HFpEF.

Trial registration: ClinicalTrials.gov NCT02446327.

Conflict of interest statement

This study was supported by a grant from the European Union (FP7-HEALTH-2010-MEDIA), by the French Programme Hospitalier de Recherche Clinique (PHRC), and by the RHU Fight-HF, a public grant overseen by the French National Research Agency (ANR) as part of the second “Investissements d’Avenir” program (reference: ANR-15-RHU-0004), the GEENAGE (ANR-15-IDEX-04-LUE) program, by the Contrat de Plan Etat Région Lorraine and FEDER IT2MP. N-LA was supported by a Miguel Servet contract CP13/00221 from the “Instituto de Salud Carlos III-FEDER”. WJP and LvH were supported by CVON, Dutch Heart Foundation, The Hague, The Netherlands (RECONNECT and EARLY-HFpEF projects). AM received speaker’s honoraria from Orion, Otsuka, Philips, Roche, and Servier. AM received fees as a member of the advisory board and/or Steering Committee and/or research grant from Adrenomed, Epygon, Neurotronik, Roche, Sanofi, and Sphyngotec. AM owns shares in S-Form Pharma. SS acknowledges funding received from the European Society of Cardiology in the form of an ESC Research Grant (R-2018-18686).

Figures

Fig. 1
Fig. 1
Network analyses for the visualization of pathways and protein interactions between circulating proteins associated with sex in MEDIA-DHF. The proteins that were higher expressed in female vs. male patients may be linked to pathways involved in lipid metabolism, transcriptional regulation, and hemostasis. The proteins that were higher expressed in male vs. female patients may be linked to pathways such as extracellular matrix organization and developmental processes. Common pathways between the proteins seem signal transduction, protein metabolism and cytokine signaling. The FHF-GKB complex network was queried in order to explore pathways and proteins that could connect together biomarker nodes of interest. Queries were expressed according to query patterns defining a path structure between two nodes such as BM-BM, BM-pathway-BM, and BM-pathway, where the BM nodes are taken from a list of interest. The resulting graphs were merged in a figure illustrating all possible paths not longer than two edges, connecting proteins through pathways and proteins. This graph depicts biomarker-pathway—protein interactions. There were no direct interactions between proteins. Blue: proteins higher expressed in males. Pink: proteins higher expressed in females. Green: pathways
Fig. 2
Fig. 2
Primary outcome according to sex. Legend: CV, cardiovascular; No., number

References

    1. Meta-analysis global group in chronic heart failure (MAGGIC) The survival of patients with heart failure with preserved or reduced left ventricular ejection fraction: an individual patient data meta-analysis. Eur Heart J. 2012;33(14):1750–1757.
    1. Dunlay SM, Roger VL, Redfield MM. Epidemiology of heart failure with preserved ejection fraction. Nat Rev Cardiol. 2017;14(10):591–602.
    1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129–2200.
    1. Tsao CW, Lyass A, Enserro D, Larson MG, Ho JE, Kizer JR, et al. Temporal Trends in the Incidence of and Mortality Associated With Heart Failure With Preserved and Reduced Ejection Fraction. JACC Heart failure. 2018;6(8):678–685.
    1. Ho JE, Gona P, Pencina MJ, Tu JV, Austin PC, Vasan RS, et al. Discriminating clinical features of heart failure with preserved vs. reduced ejection fraction in the community. Eur Heart J. 2012;33(14):1734–1741.
    1. Beale AL, Meyer P, Marwick TH, Lam CSP, Kaye DM. Sex Differences in Cardiovascular Pathophysiology: Why Women Are Overrepresented in Heart Failure With Preserved Ejection Fraction. Circulation. 2018;138(2):198–205.
    1. Stienen S, Ferreira JP, Kobayashi M, Preud'homme G, Dobre D, Machu JL, et al. Enhanced clinical phenotyping by mechanistic bioprofiling in heart failure with preserved ejection fraction: insights from the MEDIA-DHF study (The Metabolic Road to Diastolic Heart Failure). Biomarkers. 2020;25(2):201–11.
    1. Paulus WJ, Tschope C, Sanderson JE, Rusconi C, Flachskampf FA, Rademakers FE, et al. How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology. Eur Heart J. 2007;28(20):2539–2550.
    1. Assarsson E, Lundberg M, Holmquist G, Bjorkesten J, Thorsen SB, Ekman D, et al. Homogenous 96-plex PEA immunoassay exhibiting high sensitivity, specificity, and excellent scalability. PLoS One. 2014;9(4):e95192.
    1. UniProt: the universal protein knowledgebase. Nucleic acids research. 2017;45(D1):D158-d69.
    1. Kibbe WA, Arze C, Felix V, Mitraka E, Bolton E, Fu G, et al. Disease Ontology 2015 update: an expanded and updated database of human diseases for linking biomedical knowledge through disease data. Nucleic Acids Res. 2015;43(Database issue):D1071–D1078.
    1. Pinero J, Bravo A, Queralt-Rosinach N, Gutierrez-Sacristan A, Deu-Pons J, Centeno E, et al. DisGeNET: a comprehensive platform integrating information on human disease-associated genes and variants. Nucleic Acids Res. 2017;45(D1):D833–D8d9.
    1. Fabregat A, Jupe S, Matthews L, Sidiropoulos K, Gillespie M, Garapati P, et al. The Reactome Pathway Knowledgebase. Nucleic Acids Res. 2018;46(D1):D649–Dd55.
    1. Szklarczyk D, Franceschini A, Wyder S, Forslund K, Heller D, Huerta-Cepas J, et al. STRING v10: protein-protein interaction networks, integrated over the tree of life. Nucleic Acids Res. 2015;43(Database issue):D447–D452.
    1. Slenter DN, Kutmon M, Hanspers K, Riutta A, Windsor J, Nunes N, et al. WikiPathways: a multifaceted pathway database bridging metabolomics to other omics research. Nucleic Acids Res. 2018;46(D1):D661–D6d7.
    1. Calderone A, Castagnoli L, Cesareni G. mentha: a resource for browsing integrated protein-interaction networks. Nat Methods. 2013;10(8):690–691.
    1. Chatr-Aryamontri A, Oughtred R, Boucher L, Rust J, Chang C, Kolas NK, et al. The BioGRID interaction database: 2017 update. Nucleic Acids Res. 2017;45(D1):D369–Dd79.
    1. Rubin DB. Multiple Imputation for Nonresponse in Surveys. New York: John Wiley and Sons; 2004.
    1. Goyal P, Paul T, Almarzooq ZI, Peterson JC, Krishnan U, Swaminathan RV, et al. Sex- and Race-Related Differences in Characteristics and Outcomes of Hospitalizations for Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc. 2017;6:4.
    1. Lam CS, Carson PE, Anand IS, Rector TS, Kuskowski M, Komajda M, et al. Sex differences in clinical characteristics and outcomes in elderly patients with heart failure and preserved ejection fraction: the Irbesartan in Heart Failure with Preserved Ejection Fraction (I-PRESERVE) trial. Circ Heart Fail. 2012;5(5):571–578.
    1. Spinarova L, Spinar J, Vitovec J, Linhart A, Widimsky P, Fedorco M, et al. Gender differences in total cholesterol levels in patients with acute heart failure and its importance for short and long time prognosis. Biomedical papers of the Medical Faculty of the University Palacky, Olomouc, Czechoslovakia. 2012;156(1):21–28.
    1. Merz AA, Cheng S. Sex differences in cardiovascular ageing. Heart. 2016;102(11):825–831.
    1. Walsh PT, Fallon PG. The emergence of the IL-36 cytokine family as novel targets for inflammatory diseases. Ann N Y Acad Sci. 2018;1417(1):23–34.
    1. Chiu AP, Wan A, Rodrigues B. Cardiomyocyte-endothelial cell control of lipoprotein lipase. Biochim Biophys Acta. 2016;1861(10):1434–1441.
    1. He PP, Jiang T, OuYang XP, Liang YQ, Zou JQ, Wang Y, et al. Lipoprotein lipase: Biosynthesis, regulatory factors, and its role in atherosclerosis and other diseases. Clinica chimica acta; international journal of clinical chemistry. 2018;480:126–137.
    1. He H, Yang F, Liu X, Zeng X, Hu Q, Zhu Q, et al. Sex hormone ratio changes in men and postmenopausal women with coronary artery disease. Menopause (New York, NY). 2007;14(3 Pt 1):385-390.
    1. Baxter RC. IGF binding proteins in cancer: mechanistic and clinical insights. Nat Rev Cancer. 2014;14(5):329–341.
    1. Bayes-Genis A, Conover CA, Schwartz RS. The insulin-like growth factor axis: A review of atherosclerosis and restenosis. Circ Res. 2000;86(2):125–130.
    1. Bruno C, Silvestrini A, Calarco R, Favuzzi AMR, Vergani E, Nicolazzi MA, et al. Anabolic Hormones Deficiencies in Heart Failure With Preserved Ejection Fraction: Prevalence and Impact on Antioxidants Levels and Myocardial Dysfunction. Front Endocrinol (Lausanne) 2020;11:281.
    1. Lee WL, Chen JW, Ting CT, Lin SJ, Wang PH. Changes of the insulin-like growth factor I system during acute myocardial infarction: implications on left ventricular remodeling. J Clin Endocrinol Metab. 1999;84(5):1575–1581.
    1. Aneke-Nash CS, Xue X, Qi Q, Biggs ML, Cappola A, Kuller L, et al. The Association Between IGF-I and IGFBP-3 and Incident Diabetes in an Older Population of Men and Women in the Cardiovascular Health Study. J Clin Endocrinol Metab. 2017;102(12):4541–4547.
    1. Greenberg AS, Egan JJ, Wek SA, Garty NB, Blanchette-Mackie EJ, Londos C. Perilipin, a major hormonally regulated adipocyte-specific phosphoprotein associated with the periphery of lipid storage droplets. J Biol Chem. 1991;266(17):11341–11346.
    1. Zhang P, Meng L, Song L, Du J, Du S, Cui W, et al. Roles of Perilipins in Diseases and Cancers. Current genomics. 2018;19(4):247–257.
    1. Mazzali G, Fantin F, Zoico E, Sepe A, Bambace C, Faccioli S, et al. Heart Fat Infiltration In Subjects With and Without Coronary Artery Disease. J Clin Endocrinol Metab. 2015;100(9):3364–3371.
    1. Huang L, Yang Y, Yang F, Liu S, Zhu Z, Lei Z, et al. Functions of EpCAM in physiological processes and diseases (Review) Int J Mol Med. 2018;42(4):1771–1785.
    1. Bouwens E, van den Berg VJ, Akkerhuis KM, Baart SJ, Caliskan K, Brugts JJ, et al. Circulating Biomarkers of Cell Adhesion Predict Clinical Outcome in Patients with Chronic Heart Failure. J Clin Med. 2020;9:1.
    1. Zachary I. Neuropilins: role in signalling, angiogenesis and disease. Chemical immunology and allergy. 2014;99:37–70.
    1. Geretti E, Shimizu A, Klagsbrun M. Neuropilin structure governs VEGF and semaphorin binding and regulates angiogenesis. Angiogenesis. 2008;11(1):31–39.
    1. Tromp J, Khan MA, Klip IT, Meyer S, de Boer RA, Jaarsma T, et al. Biomarker profiles in heart failure patients with preserved and reduced ejection fraction. J Am Heart Assoc. 2017;6:4.
    1. DeLeon-Pennell KY, Meschiari CA, Jung M, Lindsey ML. Matrix metalloproteinases in myocardial infarction and heart failure. Prog Mol Biol Transl Sci. 2017;147:75–100.
    1. Galis ZS, Sukhova GK, Lark MW, Libby P. Increased expression of matrix metalloproteinases and matrix degrading activity in vulnerable regions of human atherosclerotic plaques. J Clin Invest. 1994;94(6):2493–2503.
    1. Kelly D, Khan S, Cockerill G, Ng LL, Thompson M, Samani NJ, et al. Circulating stromelysin-1 (MMP-3): a novel predictor of LV dysfunction, remodelling and all-cause mortality after acute myocardial infarction. Eur J Heart Fail. 2008;10(2):133–139.
    1. Humphries S, Bauters C, Meirhaeghe A, Luong L, Bertrand M, Amouyel P. The 5A6A polymorphism in the promoter of the stromelysin-1 (MMP3) gene as a risk factor for restenosis. Eur Heart J. 2002;23(9):721–725.
    1. Soro-Paavonen A, Gordin D, Forsblom C, Rosengard-Barlund M, Waden J, Thorn L, et al. Circulating ACE2 activity is increased in patients with type 1 diabetes and vascular complications. J Hypertens. 2012;30(2):375–383.
    1. Fernandez-Atucha A, Izagirre A, Fraile-Bermudez AB, Kortajarena M, Larrinaga G, Martinez-Lage P, et al. Sex differences in the aging pattern of renin-angiotensin system serum peptidases. Biol Sex Differ. 2017;8:5.
    1. Voshol PJ, Rensen PC, van Dijk KW, Romijn JA, Havekes LM. Effect of plasma triglyceride metabolism on lipid storage in adipose tissue: studies using genetically engineered mouse models. Biochim Biophys Acta. 2009;1791(6):479–485.
    1. Okubo M, Horinishi A, Saito M, Ebara T, Endo Y, Kaku K, et al. A novel complex deletion-insertion mutation mediated by Alu repetitive elements leads to lipoprotein lipase deficiency. Mol Genet Metab. 2007;92(3):229–233.
    1. Ferreira LD, Pulawa LK, Jensen DR, Eckel RH. Overexpressing human lipoprotein lipase in mouse skeletal muscle is associated with insulin resistance. Diabetes. 2001;50(5):1064–1068.
    1. Delezie J, Dumont S, Dardente H, Oudart H, Gréchez-Cassiau A, Klosen P, et al. The nuclear receptor REV-ERBα is required for the daily balance of carbohydrate and lipid metabolism. FASEB J. 2012;26(8):3321–3335.
    1. Liu S, Geng B, Zou L, Wei S, Wang W, Deng J, et al. Development of hypertrophic cardiomyopathy in perilipin-1 null mice with adipose tissue dysfunction. Cardiovasc Res. 2015;105(1):20–30.
    1. Li F, Zhao H, Liao Y, Takashima S, Asano Y, Shintani Y, et al. Higher mortality in heterozygous neuropilin-1 mice after cardiac pressure overload. Biochem Biophys Res Commun. 2008;370(2):317–321.
    1. Kittana N. Angiotensin-converting enzyme 2-Angiotensin 1-7/1-9 system: novel promising targets for heart failure treatment. Fundam Clin Pharmacol. 2018;32(1):14–25.
    1. Sama IE, Ravera A, Santema BT, van Goor H, Ter Maaten JM, Cleland JGF, et al. Circulating plasma concentrations of angiotensin-converting enzyme 2 in men and women with heart failure and effects of renin-angiotensin-aldosterone inhibitors. Eur Heart J. 2020;41(19):1810–1817.
    1. Felkin LE, Birks EJ, George R, Wong S, Khaghani A, Yacoub MH, et al. A quantitative gene expression profile of matrix metalloproteinases (MMPS) and their inhibitors (TIMPS) in the myocardium of patients with deteriorating heart failure requiring left ventricular assist device support. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation. 2006;25(12):1413–1419.
    1. Pandit R, Beerens S, Adan RAH. Role of leptin in energy expenditure: the hypothalamic perspective. Am J Phys Regul Integr Comp Phys. 2017;312(6):R938–RR47.
    1. Schwartz MW, Seeley RJ, Campfield LA, Burn P, Baskin DG. Identification of targets of leptin action in rat hypothalamus. J Clin Invest. 1996;98(5):1101–1106.
    1. Faxén UL, Hage C, Andreasson A, Donal E, Daubert JC, Linde C, et al. HFpEF and HFrEF exhibit different phenotypes as assessed by leptin and adiponectin. Int J Cardiol. 2017;228:709–716.
    1. Flanagan DE, Vaile JC, Petley GW, Phillips DI, Godsland IF, Owens P, et al. Gender differences in the relationship between leptin, insulin resistance and the autonomic nervous system. Regul Pept. 2007;140(1-2):37–42.
    1. Packer M. Leptin-aldosterone-neprilysin axis: identification of its distinctive role in the pathogenesis of the three phenotypes of heart failure in people with obesity. Circulation. 2018;137(15):1614–1631.
    1. Chang E, Varghese M, Singer K. Gender and sex differences in adipose tissue. Curr Diab Rep. 2018;18(9):69.
    1. Paulus WJ, Tschöpe C. A novel paradigm for heart failure with preserved ejection fraction: comorbidities drive myocardial dysfunction and remodeling through coronary microvascular endothelial inflammation. J Am Coll Cardiol. 2013;62(4):263–271.
    1. Hvas AM, Favaloro EJ. Gender related issues in thrombosis and hemostasis. Expert Rev Hematol. 2017;10(11):941–949.
    1. Kessler EL, Rivaud MR, Vos MA, van Veen TAB. Sex-specific influence on cardiac structural remodeling and therapy in cardiovascular disease. Biol Sex Differ. 2019;10(1):7.
    1. Cavasin MA, Tao Z, Menon S, Yang XP. Gender differences in cardiac function during early remodeling after acute myocardial infarction in mice. Life Sci. 2004;75(18):2181–2192.
    1. McMurray JJV, Jackson AM, Lam CSP, Redfield MM, Anand IS, Ge J, et al. Effects of sacubitril-valsartan, versus valsartan, in women compared to men with heart failure and preserved ejection fraction: Insights from PARAGON-HF. Circulation. 2019.
    1. Martinez-Selles M, Doughty RN, Poppe K, Whalley GA, Earle N, Tribouilloy C, et al. Gender and survival in patients with heart failure: interactions with diabetes and aetiology. Results from the MAGGIC individual patient meta-analysis. Eur J Heart Fail. 2012;14(5):473–479.
    1. Lew J, Sanghavi M, Ayers CR, McGuire DK, Omland T, Atzler D, et al. Sex-based differences in cardiometabolic biomarkers. Circulation. 2017;135(6):544–555.
    1. Rossignol P, Hernandez AF, Solomon S, Zannad F. Heart failure drug treatment. Lancet. 2019;in press.
    1. Solomon SD, McMurray JJV, Anand IS, Ge J, Lam CSP, Maggioni AP, et al. Angiotensin-neprilysin inhibition in heart failure with preserved ejection fraction. N Engl J Med. 2019;381(17):1609–1620.
    1. Solomon SD, Claggett B, Lewis EF, Desai A, Anand I, Sweitzer NK, et al. Influence of ejection fraction on outcomes and efficacy of spironolactone in patients with heart failure with preserved ejection fraction. Eur Heart J. 2016;37(5):455–462.
    1. Linde C, Cleland JGF, Gold MR, Claude Daubert J, Tang ASL, Young JB, et al. The interaction of sex, height, and QRS duration on the effects of cardiac resynchronization therapy on morbidity and mortality: an individual-patient data meta-analysis. Eur J Heart Fail. 2018;20(4):780–791.
    1. Huttin O, Fraser AG, Coiro S, Bozec E, Selton-Suty C, Lamiral Z, et al. Impact of changes in consensus diagnostic recommendations on the echocardiographic prevalence of diastolic dysfunction. J Am Coll Cardiol. 2017;69(25):3119–3121.
    1. Reddy YNV, Carter RE, Obokata M, Redfield MM, Borlaug BA. A simple, evidence-based approach to help guide diagnosis of heart failure with preserved ejection fraction. Circulation. 2018;138(9):861–870.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe