Cytokines as new treatment targets in chronic heart failure
© BioMed Central Ltd 2001
Published: 16 October 2001
Inflammatory cytokines may negatively influence contractility and contribute to the remodelling process in the failing myocardium. Traditional cardiovascular drugs appear to have little influence on the overall cytokine network in chronic heart failure (CHF). Increased interest in anticytokine therapy has therefore evolved. Several small studies have used tumour necrosis factor (TNF)-α as a target, resulting in improved functional capacity and myocardial performance. Intravenous immunoglobulin (IVIG) represents another therapeutic approach in which the impact on myocardial performance appears to be correlated with anti-inflammatory effects. These studies demonstrate potential for immunomodulation as a therapy in addition to conventional cardiovascular treatment in CHF, but the most effective drugs in this regard have yet to be identified.
Keywordschronic heart failure cytokines immunomodulating therapy intravenous immunoglobulin
The accepted paradigms and treatment strategies for heart failure have changed during the past 50 years. Traditionally, patients with CHF were treated with diuretics, vasodilators and inotropic drugs, resulting in improvement in functional status and symptoms, but with no decrease in long-term mortality [1,2]. However, the initial haemodynamic dysfunction of CHF has downstream effects on cardiovascular reflexes, and systemic organ perfusion and function. The arterial under-filling is sensed by baroreceptors that activate powerful neurohormones, which act as effectors of vasoconstriction and of avid sodium and water retention. Recognition of neurohormones as important substances in the pathogenesis of CHF has resulted in several new treatment modalities, including angiotensin-converting enzyme (ACE) inhibitors, aldosterone antagonists and β-blockers, which yield marked improvements in morbidity and mortality of CHF patients [3,4,5,6,7].
Despite 'state of the art' cardiovascular treatment, CHF is still a progressive disease with high morbidity and mortality, suggesting that important pathogenic mechanisms remain active and unmodified by the present treatment modalities. Persistent immune activation and inflammation may represent such 'unmodified mechanisms'. Attention has focused on mediators that are classically associated with innate immunity, including inflammatory cytokines .
Cytokines as pathogenic mediators of chronic heart failure
Several studies have demonstrated that CHF patients are characterized by persistent immune activation in vivo. This is reflected in increased circulating levels of inflammatory cytokines (TNF-α, IL-1β and IL-6) and chemokines (monocyte chemoattractant protein [MCP]-1 and IL-8), as well as enhanced expression of various inflammatory mediators (TNF-α, IL-6 and adhesion molecules) within the failing myocardium, independent of the cause of CHF [10,11,12,13,14,15,16,17,18,19,20].
Although there is a lack of specificity of cytokine activation in patients with CHF, several lines of evidence suggest that these inflammatory mediators are not only markers of immune activation (an epiphenomenon in severely ill patients), but may also play a pathogenic role in CHF. The pathogenic role of inflammatory cytokines in CHF is supported by research conducted in mouse models. First, transgenic mice with cardiac-specific overexpression of TNF-α developed dilated cardiomyopathy . Second, systemic administration of TNF-α, even at concentrations comparable to those found in the circulation of CHF patients, have been shown to induce a dilated-cardiomyopathy-like phenotype in animal models .
Inflammatory cytokines may modulate cardiovascular functions by a variety of mechanisms (Fig. 1). Cytokines such as TNF-α and IL-1β have been shown to depress myocardial contractility. This may be due to uncoupling of β-adrenergic signalling, increase in cardiac nitric oxide, or alterations in intracellular calcium homeostasis [23,24,25,26]. TNF-α, and members of the IL-6 family, may also induce structural changes in the failing myocardium such as cardiomyocyte hypertrophy and interstitial fibrosis [27,28]. Additionally, TNF-α and IL-1β may promote cardiomyocyte apoptosis as well as activate metalloproteinases and impair the expression of their inhibitors, possibly contributing to cardiac remodelling [29,30,31].
Stimuli for cytokine expression in chronic heart failure
Autoimmunity and various microbes are known to play pathogenic roles in subgroups of idiopathic dilated cardiomyopathy (IDCM) patients, and such mechanisms could clearly promote enhanced cytokine levels in CHF. However, raised cytokine levels appear not to be restricted to IDCM, but are also found in ischaemic cardiomyopathy. Infection with certain microbes (Chlamydia pneumoniae and cytomegalovirus) has recently been suggested to be involved in the pathogenesis of atherosclerosis. Microbial antigens may also induce myocardial damage through molecular mimicry (Fig. 1) [32,33,34]. Moreover, endotoxins have been suggested to trigger immune activation in patients with CHF during oedematous episodes, possibly following leakage from the gastrointestinal tract . Accordingly, persistent stimulation by microbial antigens might well lead to cytokine activation in CHF patients (Fig. 1). Elevation in cytokine levels seems to occur in CHF independently of chronic infection, however, and several other factors may lead to an enhanced inflammatory response in such patients.
Both mechanical overload and shear stress may induce cytokine expression (MCP-1 and IL-8) in both endothelial and smooth muscle cells . Moreover, hypoxia and ischaemia have been found to be potent inducers of inflammatory cytokines (TNF-α, MCP-1 and IL-8) within the myocardium. This may occur through production of reactive oxygen species, with secondary activation of the transcriptional factor nuclear factor-κB [37,38]. Finally, oxidized low-density lipoprotein cholesterol may increase cytokine expression (IL-1β, TNF-α, IL-6 and IL-8) in endothelial cells and monocytes, and such mechanisms may be of particular importance in myocardial failure secondary to coronary artery disease . The relative importance of the stimuli for cytokine production in various forms of CHF is uncertain, however.
Are parameters of immune activation prognostic markers in chronic heart failure?
The persistent immune activation in CHF has been reported to occur independently of the aetiology of heart failure [11,18], possibly representing a final common pathogenic pathway in this disorder. Several studies have reported raised plasma levels of inflammatory cytokines in direct relation to deterioration of functional class and cardiac performance (left ventricular ejection fraction [LVEF]) [11,12,13]. Even more importantly, it appears that these inflammatory mediators may provide important prognostic information in CHF patients. For example, in a substudy of the Studies on Left Ventricular Dysfunction (SOLVD) , patients with TNF-α plasma levels of less than 6.5 pg/ml had a better prognosis than did patients with higher levels. Moreover, in a recent report from a large population of CHF patients (the cytokine database from the Vesnarinone Trial [VEST]) [40,41], circulating levels of inflammatory cytokines (TNF-α and IL-6) and cytokine receptors (soluble TNF receptors) were found to be independent predictors of mortality in patients with advanced heart failure. These new clinical data further support the notion that raised levels of cytokines in CHF patients are not only epiphenomena, but also may reflect important pathogenic mechanisms in such patients.
Effect of cardiovascular therapy on cytokine levels in chronic heart failure patients
There are few data on how traditional cardiovascular medications influence the persistent immune activation that occurs in CHF. In the Prospective Randomized Amlodipine Survival Evaluation (PRAISE) trial , the calcium channel blocker amlodipine was found to reduce IL-6 levels, which has also been suggested to be important to the beneficial effect of this agent on mortality in patients with IDCM. However, amlodipine had no effect on TNF-α levels. Furthermore, we recently showed that high-dose ACE inhibition with enalapril causes a marked decrease in IL-6 bioactivity, associated with reduction in left ventricular septum thickness . Thus, it is possible that an important 'antihypertrophic' mechanism of ACE inhibitors on the myocardium may be a reduction in IL-6 levels, possibly combined with impaired IL-6 signal transduction. Except for a favourable effect on IL-6, all of the other immunological parameters were markedly elevated in CHF patients and remained unchanged during treatment with enalapril.
Interestingly, other investigators have reported that ACE inhibitors may prevent nuclear factor-κB activation and MCP-1 expression, and reduce macrophage infiltration in both experimental and clinical atherosclerosis [44,45]. Additionally, a combination of ACE inhibitors and angiotensin receptor antagonists was recently found to reduce cardiac infiltration of macrophages following acute myocardial infarction in rats . Whether ACE inhibitors have such effects in CHF patients must be addressed in future studies.
Several studies have shown that β-adrenergic stimulation may modulate cytokine production in various lymphocyte subsets and monocytes . In rats, adrenergic activation has been found to increase myocardial expression of inflammatory cytokines (TNF-α and IL-1), which was reduced by β-adrenergic blockade (metoprolol) . This may not to be the case in CHF patients, however. A non-placebo-controlled study in patients with IDCM  reported some suppressive effects of β-blockers on plasma levels of both inflammatory (TNF-α) and anti-inflammatory (IL-10) cytokines. However, we have recently shown  that long-term treatment with the β1-selective blocker metoprolol CR/XL had no significant effect on cytokine levels, as compared with placebo, in patients with CHF. It remains to be determined whether more complete blockade of the β-receptors (i.e. nonselective), or combined α- and β-blockade with carvedilol alters the cytokine network.
Finally, several studies have suggested that statins may exert direct cardiovascular effects, such as attenuating inflammatory responses and promoting plaque stability, that are clearly independent of their cholesterol-lowering effects. Statins reduce C-reactive protein (CRP) levels and may be effective in preventing coronary events in patients with relatively low lipid levels but with elevated CRP . Standard aspirin treatment also appears to reduce IL-6 and CRP levels in patients with stable angina . Reduction in cytokine and CRP levels by statins and aspirin may well explain part of their therapeutic action. However, their effects in reducing systemic and myocardial inflammation in CHF patients require further assessment.
The cytokine network as new targets for therapy in myocardial failure?
Given the central role of TNF-α in the pathogenesis of CHF, therapeutic modulation targeting this cytokine has received much attention. Preliminary reports suggest that TNF-α inhibition with recombinant chimeric soluble TNF receptor type 2 (etanercept) may have beneficial effects on cardiac performance in CHF patients [53,54]. However, anticytokine therapy with soluble TNF receptors may have some limitations. Recent studies in animal models showed that, although such therapy decreased plasma cytokine levels, there was no decrease in IL-6 and MCP-1 levels within the myocardium. Notably, the Randomized Etanercept North American Strategy to Study Antagonism of Cytokine (RENAISSANCE) and the Research into Etanercept: Cytokine Antagonism in Ventricular function (RECOVER) outcome studies of etanercept were recently stopped because of lack of evidence of beneficial effects [62,63]. The studies had randomized over 1500 patients and were due to be completed at the end of 2001, but interim analysis revealed no likelihood of a difference between etanercept and placebo developing if the studies had run to completion.
Pentoxifylline is a xanthine-derived agent that has been shown to inhibit various inflammatory cytokines such as TNF-α, IL-1β and interferon-γ. Recently, addition of pentoxifylline to treatment with digoxin, ACE inhibitors and carvedilol in patients with IDCM was shown to be associated with a significant improvement in symptoms and LVEF [55,56]. That was in a single-centre, prospective, double-blind, randomized, placebo-controlled study. Thirty-nine patients with IDCM and LVEF below 40% were randomly assigned to pentoxifylline (400 mg three times daily; n = 20) or placebo (n = 19).
Although the published studies with etanercept and pentoxifylline are small, the improvement in LVEF appears to be greater with pentoxifylline. Furthermore, other advantages of pentoxifylline over etanercept are its easier form of administration, lower cost and that it might inhibit the production of TNF-α rather than neutralize its effects. Although large-scale trials are needed to evaluate the safety of pentoxifylline in patients with CHF, this drug has been used in patients with peripheral vascular disease for more than 25 years with a very low incidence of side effects.
Therapy with IVIG has been evaluated in a wide range of immune-mediated disorders, such as Kawasaki syndrome, dermatomyositis and multiple sclerosis [64,65]. Beneficial effects of IVIG have also been suggested in acute and peripartum cardiomyopathy [66,67].
Recently, we demonstrated that IVIG significantly improves LVEF by 5% in CHF patients, independent of the aetiology of heart failure . That was a double-blind, placebo-controlled study, with 40 CHF patients (both ischaemic and IDCM with LVEF below40%). IVIG also improved some haemodynamic variables (pulmonary capillary wedge pressure) and exercise capacity. IVIG, but not placebo, was accompanied by a marked but gradual decline in plasma levels of amino-terminal pro-atrial natriuretic peptide. In contrast, a recent study conducted by McNamara et al.  found no significant impact of IVIG, as compared with placebo, on recent-onset IDCM. Although this may be due to the marked improvement in the study group as a whole (with or without IVIG), it is noteworthy that the dosage schedule differs between the 'IDCM' and the 'CHF' study.
Although both studies described above gave induction therapy, maintenance therapy (monthly infusions for a total of 5 months) was only given in the 'CHF' study . Notably, in the 'CHF' study there was as a gradual decline in amino-terminal pro-atrial natriuretic peptide throughout, which became pronounced at the end of study. Moreover, a recent follow-up study (Gullestad L, Aukrust P, unpublished data) showed that most of the CHF patients in the IVIG group had a decrease in LVEF 1 year after termination of the study. Those data suggest that maintenance therapy is needed for an extended period of time, as in other chronic inflammatory disorders.
Several modes of action may be of importance for the clinical effects of IVIG in inflammatory disorders, such as neutralization of microbial antigens, Fc-receptor blockade and impairment of apoptosis [64,69]. In our opinion, however, particular attention should be drawn toward the effect of IVIG on the cytokine network. In the IVIG study the improvement in LVEF was associated with a marked rise in the anti-inflammatory mediators IL-10, IL-1 receptor antagonist and soluble TNF receptor, which was accompanied by a slight decrease in TNF-α and IL-1β . This suggests an anti-inflammatory net effect with potential beneficial results on the myocardium. Taken together with the imbalance between pro- and anti-inflammatory cytokines in CHF patients , upregulation or administration of anti-inflammatory cytokines such as IL-10 might be a useful strategy for intervention in CHF patients. Interestingly, administration of IL-10 has recently been shown to have therapeutic effects on murine viral myocarditis .
Finally, we also reported that IVIG therapy, but not placebo, may downregulate chemokines and their receptors on peripheral blood mononuclear cells in CHF patients, possibly contributing to the beneficial effect of IVIG in CHF . Accordingly, direct blockade of the chemokine network may represent another interesting approach for future intervention in CHF patients.
Recently, the technique of immunoadsorption has been used in several studies to treat patients with IDCM . Immunoadsorption has been found to improve functional capacity, and left ventricular structure and function in IDCM patients . The mechanisms that underlie these effects may involve removal of circulating antibodies to β1-adreno-receptors, reduction in oxidative stress and mitigation of myocardial inflammation [70,71,72]. IVIG replacement therapy is often given to these patients and, as discussed above, may per se lead to improvement in clinical status in patients with IDCM [58,70].
Although not necessarily the 'drugs of choice', recent studies of various anticytokine (etanercept) and immunomodulating agents (IVIG and pentoxifylline) in CHF patients clearly suggest a potential for such therapies in these patients, in addition to 'optimal' cardiovascular treatment regimens. However, the results in these small studies will have to be confirmed in larger, placebo-controlled mortality studies. Several studies have focused on the possible pathogenic role of TNF-α, and targeted therapy against this molecule is ongoing. In order to develop more specific immunomodulating agents in the immunopathogenesis of CHF, further research will need to identify precisely the important players. Regardless of these shortcomings, we believe that cytokines might lead to quite new treatment modalities in CHF, resulting in reduced morbidity and mortality in such patients.
chronic heart failure
idiopathic dilated cardiomyopathy
left ventricular ejection fraction
monocyte chemoattractant protein
- TNF = tumour necrosis factor. VEST = Vesnarinone Trial. SOLVD = Studies on Left Ventricular Dysfunction. RENAISSANCE = Randomized Etanercept North American Strategy to Study Antagonism of Cytokine. RECOVER = Research into Etanercept:
Cytokine Antagonism in Ventricular function.
- Cohn JN, Archibald DG, Ziesche S, Franciosa JA, Harston WE, Tristani FE, Dunkman WB, Jacobs W, Francis GS, Flohr KH, et al: Effect of vasodilator therapy on mortality in chronic heart failure. Results of a Veterans Administration cooperative study (V-HeFT). N Engl J Med. 1986, 314: 1547-1552.View ArticlePubMedGoogle Scholar
- Packer M, Carver JR, Rodeheffer RJ, Ivanhoe RJ, DiBianco R, Zeldis SM, Hendrix GH, Bommer WJ, Elkayam U, Kukin ML, et al: Effect of milrinone on mortality in severe heart failure. The PROMISE Study Research Group. N Engl J Med. 1991, 325: 1468-1475.View ArticlePubMedGoogle Scholar
- The CONSENSUS Trial Study Group: Effects of enalapril on mortality in severe congestive heart failure. N Engl J Med. 1987, 316: 1429-1435.View ArticleGoogle Scholar
- Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, Palensky J, Wittes J: The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators (RALES). N Engl J Med. 1999, 341: 709-717.View ArticlePubMedGoogle Scholar
- MERIT-HF Study Group: Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet. 1999, 353: 2001-2007.View ArticleGoogle Scholar
- CIBIS-II Investigators and Commitee: The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet. 1999, 353: 9-13.View ArticleGoogle Scholar
- Packer M, Bristow MR, Cohn JN, Colucci WS, Fowler MB, Gilbert EM, Shusterman NH, for the US Carvedilol Heart Failure Study Group: The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med. 1996, 334: 1349-1355.View ArticlePubMedGoogle Scholar
- Medzhitov R, Janeway C: Innate immunity. N Engl J Med. 2000, 343: 338-344.View ArticlePubMedGoogle Scholar
- Beutler B, van Huffel C: Unraveling function in the TNF ligand and receptor families. Science. 1994, 264: 667-668.View ArticlePubMedGoogle Scholar
- Levine B, Kalman J, Mayer L, Fillit HM, Packer M: Elevated circulating levels of tumor necrosis factor in severe chronic heart failure. N Engl J Med. 1990, 323: 236-241.View ArticlePubMedGoogle Scholar
- Aukrust P, Ueland T, Lien E, Bendtzen K, Muller F, Andreassen AK, Nordoy I, Aass H, Espevik T, Simonsen S, Froland SS, Gullestad L: Cytokine network in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1999, 83: 376-382.View ArticlePubMedGoogle Scholar
- Testa M, Yeh M, Lee P, Fanelli R, Loperfido F, Berman JW, LeJem-tel TH: Circulating levels of cytokines and their endogenous modulators in patients with mild to severe congestive heart failure due to coronary artery disease or hypertension. J Am Coll Cardiol. 1996, 28: 964-971.View ArticlePubMedGoogle Scholar
- Torre-Amione G, Kapadia S, Benedict C, Oral H, Young JB, Mann DL: Proinflammatory cytokine levels in patients with depressed left ventricular ejection fraction: a report from the studies of left ventricular dysfunction (SOLVD). J Am Coll Cardiol. 1996, 27: 1201-1206.View ArticlePubMedGoogle Scholar
- Munger MA, Johnson B, Amber IJ, Callahan KS, Gilbert EM: Circulating concentrations of proinflammatory cytokines in mild or moderate heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1996, 77: 423-427.View ArticleGoogle Scholar
- Aukrust P, Ueland T, Muller F, Andreassen AK, Nordoy I, Aas H, Kjekshus J, Simonsen S, Froland SS, Gullestad L: Elevated circulating levels of C-C chemokines in patients with congestive heart failure. Circulation. 1998, 97: 1136-1143.View ArticlePubMedGoogle Scholar
- Damas JK, Gullestad L, Ueland T, Solum NO, Simonsen S, Froland SS, Aukrust P: CXC-chemokines, a new group of cytokines in congestive heart failure–possible role of platelets and monocytes. Cardiovasc Res. 2000, 45: 428-436.View ArticlePubMedGoogle Scholar
- Torre-Amione G, Kapadia S, Lee J, Durand JB, Bies RD, Young JB, Mann DL: Tumor necrosis factor-α and tumor necrosis factor receptors in the failing human heart. Circulation. 1996, 93: 704-711.View ArticlePubMedGoogle Scholar
- Devaux B, Scholz D, Hirche A, Klovekorn WP, Schaper J: Upreg-ulation of cell adhesion molecules and the presence of low grade inflammation in human chronic heart failure. Eur Heart J. 1997, 18: 470-479.View ArticlePubMedGoogle Scholar
- Damas JK, Eiken HG, Oie E, Bjerkeli V, Yndestad A, Ueland T, Tonnessen T, Geiran OR, Aass H, Simonsen S, Christensen G, Froland SS, Attramadal H, Gullestad L, Aukrust P: Myocardial expression of CC- and CXC-chemokines and their receptors in human end-stage heart failure. Cardiovasc Res. 2000, 47: 778-787.View ArticlePubMedGoogle Scholar
- Eiken HG, Oie E, Damas JK, Yndestad A, Bjerkeli V, Aass H, Simonsen S, Geiran OR, Tonnessen T, Christensen G, Froland SS, Gullestad L, Attramadal H, Aukrust P: Myocardial gene expression of leukemia inhibitory factor, interleukin-6 and glycoprotein 130 in end-stage human heart failure. Eur J Clin Invest. 2001, 31: 389-397.View ArticlePubMedGoogle Scholar
- Kubota T, McTiernan CF, Frye CS, Slawson SE, Lemster BH, Koretsky AP, Demetris AJ, Feldman AM: Dilated cardiomyopathy in transgenic mice with cardiac-specific overexpression of tumor necrosis factor-alpha. Circ Res. 1997, 81: 627-635.View ArticlePubMedGoogle Scholar
- Bozkurt B, Kribbs SB, Clubb FJ, Michael LH, Didenko VV, Hornsby PJ, Seta Y, Oral H, Spinale FG, Mann DL: Pathophysiologically relevant concentrations of tumor necrosis factor-alpha promote progressive dysfunction and remodelling in rats. Circulation. 1998, 97: 1382-1391.View ArticlePubMedGoogle Scholar
- Yokoyama T, Vaca L, Rossen RD, Durante W, Hazarika P, Mann DL: Cellular basis for the negative inotropic effects of tumor necrosis factor-α in the mammalian heart. J Clin Invest. 1993, 92: 2303-2312.PubMed CentralView ArticlePubMedGoogle Scholar
- Gulick TS, Chung MK, Pieper SJ, Lange LG: Interleukin-1 and tumor necrosis factor inhibit cardiac myocyte β-adrenergic responsiveness. Proc Natl Acad Sci USA. 1989, 86: 6753-6757.PubMed CentralView ArticlePubMedGoogle Scholar
- Finkel MS, Oddis CV, Jacob TD, Watkins SC, Hattler BG, Simmons RL: Negative inotropic effects of cytokines on the heart mediated by nitric oxide. Science. 1992, 257: 387-389.View ArticlePubMedGoogle Scholar
- Goldhaber JI, Kim KH, Natterson PD, Lawrence T, Yang P, Weiss JN: Effects of TNF-alpha on [Ca2+]i and contractility in isolated adult rabbit ventricular myocytes. Am J Physiol. 1996, 271: H1449-H1455.PubMedGoogle Scholar
- Yokoyama T, Nakano M, Bednarczyk JL, McIntyre BW, Entman M, Mann DL: Tumor necrosis factor-alpha provokes a hypertrophic growth response in adult cardiac myocytes. Circulation. 1997, 95: 1247-1252.View ArticlePubMedGoogle Scholar
- Hirota H, Chen J, Betz UA, Rajewsky K, Gu Y, Ross J, Muller W, Chien KR: Loss of a gp130 cardiac muscle cell survival pathway is a critical event in the onset of heart failure during biomechanical stress. Cell. 1999, 97: 189-198.View ArticlePubMedGoogle Scholar
- Krown KA, Page MT, Nguyen C, Zechner D, Gutierrez V, Comstock KL, Glembotski CC, Quintana PJ, Sabbadini RA: Tumor necrosis factor alpha-induced apoptosis in cardiac myocytes. J Clin Invest. 1996, 98: 2854-2865.PubMed CentralView ArticlePubMedGoogle Scholar
- Pulkki KJ: Cytokines and cardiomyocyte death. Ann Med. 1997, 29: 339-343.View ArticlePubMedGoogle Scholar
- Li YY, Feng YQ, Kadokami T, McTiernan CF, Draviam R, Watkins SC, Feldman AM: Myocardial extracellular matrix remodeling in transgenic mice overexpressing tumor necrosis factor alpha can be modulated by anti-tumor necrosis factor alpha therapy. Proc Natl Acad Sci USA. 2000, 97: 12746-12751.PubMed CentralView ArticlePubMedGoogle Scholar
- Becker AE, de Boer OJ, van Der Wal AC: The role of inflammation and infection in coronary artery disease. Ann Rev Med. 2001, 52: 289-297.View ArticlePubMedGoogle Scholar
- Bachmaier K, Neu N, de la Maza LM, Pal S, Hessel A, Penninger JM: Chlamydia infections and heart disease linked through antigenic mimicry. Science. 1999, 283: 1335-1339. 10.1126/science.283.5406.1335.View ArticlePubMedGoogle Scholar
- Gauntt CJ, Arizpe HM, Higdon AL, Wood HJ, Bowers DF, Rozek MM, Crawley R: Molecular mimicry, anti-coxackievirus B3 neutralizing monoclonal antibodies, and myocarditis. J Immunol. 1995, 154: 2983-2995.PubMedGoogle Scholar
- Niebauer J, Volk HD, Kemp M, Dominguez M, Schumann RR, Rauchhaus M, Poole-Wilson PA, Coats AJ, Anker SD: Endotoxin and immune activation in chronic heart failure: a prospective cohort study. Lancet. 1999, 353: 1838-1842.View ArticlePubMedGoogle Scholar
- Okada M, Matsumori A, Ono K, Furukawa Y, Shioi T, Iwasaki A, Mat-sushima K, Sasayama S: Cyclic stretch upregulates production of interleukin-8 and monocyte chemotactic and activating factor/monocyte chemoattractant protein-1 in human endothelial cells. Arterioscler Thromb Vasc Biol. 1998, 18: 894-901.View ArticlePubMedGoogle Scholar
- Singal PK, Khaper N, Palace V, Kumar D: The role of oxidative stress in the genesis of heart disease. Cardiovasc Res. 1998, 40: 426-432.View ArticlePubMedGoogle Scholar
- Li N, Karin M: Is the NF-κB the sensor of oxidative stress?. FASEB J. 1999, 13: 1137-1143.PubMedGoogle Scholar
- Janabi M, Yamashita S, Hirano K, Sakai N, Hiraoka H, Matsumoto K, Zhang Z, Nozaki S, Matsuzawa Y: Oxidized LDL-induced NF-kappa B activation and subsequent expression of proinflammatory genes are defective in monocyte-derived macrophages from CD36-deficient patients. Arterioscler Thromb Vasc Biol. 2000, 20: 1953-1960.View ArticlePubMedGoogle Scholar
- Cohn JN, Goldstein SO, Greenberg BH, Lorell BH, Bourge RC, Jaski BE, Gottlieb SO, McGrew F, DeMets DL, White BG: A dose-dependent increase in mortality with vesnarinone among patents with severe heart failure. Vesnarinone Trial Investigators. N Engl J Med. 1998, 339: 1810-1816.View ArticlePubMedGoogle Scholar
- Deswal A, Petersen NJ, Feldman AM, Young JB, White BG, Mann DL: Cytokines and cytokine receptors in advanced heart failure: an analysis of the cytokine database from the Vesnarinone Trial (VEST). Circulation. 2001, 103: 2055-2059.View ArticlePubMedGoogle Scholar
- Mohler ER, Sorensen LC, Ghali JK, Schocken DD, Willis PW, Bowers JA, Cropp AB, Pressler ML: Role of cytokines in the mechanism of action of amlodipine: the PRAISE heart failure trial. J Am Coll Cardiol. 1997, 30: 35-41.View ArticlePubMedGoogle Scholar
- Gullestad L, Aukrust P, Ueland T, Espevik T, Yee G, Vagelos R, Froland SS, Fowler M: Effect of high-versus low-dose angiotensin converting enzyme inhibition on cytokine levels in chronic heart failure. J Am Coll Cardiol. 1999, 34: 2061-2067.View ArticlePubMedGoogle Scholar
- Hernandez-Presa M, Bustos C, Ortega M, Tunon J, Renedo G, Ruiz-Egido J: Angiotensin-converting enzyme inhibition prevents arterial factor-kappa B activation, monocyte chemoat-tractant protein-1 expression, and macrophage infiltration in a rabbit model of accelerated atherosclerosis. Circulation. 1997, 95: 1532-1541.View ArticlePubMedGoogle Scholar
- Soejima H, Ogawa H, Yasue H, Kaikita K, Takazoe K, Nishiyama K, Miyamoto S, Yoshimura M, Kugiyama K, Tsuji I: Angiotensin-converting enzyme inhibitin reduces monocyte chemoattractant protein-1 and tissue factor levels in patients with myocardial infarction. J Am Coll Cardiol. 1999, 34: 983-988.View ArticlePubMedGoogle Scholar
- Yu CM, Tipoe GL, Lai KWH, Lau CP: Effects of combination of angiotensin-converting enzyme inhibitor and angiotensin receptor antagonist on inflammatory cellular infiltration and myocardial fibrosis after acute myocardial infarction. J Am Coll Cardiol. 2001, 38: 1207-1215.View ArticlePubMedGoogle Scholar
- Maisel AS, Murray D, Lotz M, Rearden A, Irwin M, Michel MC: Propranolol treatment affects parameters of human immunity. Immunopharmacology. 1991, 22: 157-164.View ArticlePubMedGoogle Scholar
- Prabhu SD, Chandrasekar B, Murray DR, Freeman GL: beta-adrenergic blockade in developing heart failure: effects on myocardial inflammatory cytokines, nitric oxide, and remodeling. Circulation. 2000, 101: 2103-2109.View ArticlePubMedGoogle Scholar
- Ohtsuka T, Hamada M, Hiasa G, Sasaki O, Suzuki M, Hara Y, Shigematsu Y, Hiwada K: Effects of beta-blockers on circulating levels of inflammatory and anti-inflammatory cytokines in patients with dilated cardiomyopathy. J Am Coll Cardiol. 2001, 37: 412-417.View ArticlePubMedGoogle Scholar
- Gullestad L, Ueland T, Brunsvig A, Kjekshus J, Simonsen S, Froland SS, Aukrust P: Effect of metoprolol on cytokine levels in chronic heart failure: a substudy in the MERIT-HF trial. Am Heart J. 2001, 141: 418-421.View ArticlePubMedGoogle Scholar
- Ridker PM, Rifai N, Clearfield M, Downs JR, Weis SE, Miles JS, Gotto AM: Measurement of C-reactive protein for the targeting of statin therapy in the primary prevention of acute coronary events. N Engl J Med. 2001, 344: 1959-1965.View ArticlePubMedGoogle Scholar
- Ikonomidis I, Androetti F, Economou E, Stefanadis C, Toutouzas P, Nihoyannopoulos P: Increased proinflammatory cytokines in patients with chronic stable angina and their reduction by aspirin. Circulation. 1999, 100: 793-798.View ArticlePubMedGoogle Scholar
- Deswal A, Bozkurt B, Seta Y, Parilti-Eiswirth S, Hayes FA, Blosch C, Mann DL: Safety and efficacy of a soluble p75 tumor necrosis factor receptor (Enbrel, Etanercept) in patients with advanced heart failure. Circulation. 1999, 99: 3224-3226.View ArticlePubMedGoogle Scholar
- Bozkurt B, Torre-Amione , Smith Warren M, Whitmore J, Soran OZ, Feldman AM, Mann DL: Results of targeted anti-tumor necrosis factor therapy with etanercept (ENBREL) in patients with advanced heart failure. Circulation. 2001, 103: 1044-1047.View ArticlePubMedGoogle Scholar
- Sliwa K, Skudicky D, Candy G, Wisenbaugh T, Sareli P: Randomized investigation of effects of pentoxifylline on left ventricular performance in idiopathic dilated cardiomyopathy. Lancet. 1998, 351: 1091-1093.View ArticlePubMedGoogle Scholar
- Skudicky D, Bergmann A, Sliwa K, Candy G, Sareli P: Beneficial effects of pentoxifylline in patients with idiopathic dilated cardiomyopathy treated with angiotensin-converting enzyme inhibitors and carvedilol. Circulation. 2001, 103: 1083-1088.View ArticlePubMedGoogle Scholar
- Davey PP, Ashrafian H: New therapies for heart failure: is thalidomide the answer?. Q J Med. 2000, 93: 305-311.View ArticleGoogle Scholar
- Gullestad L, Aass H, Fjeld JG, Wikeby L, Andreassen AK, Ihlen H, Simonsen S, Kjekshus J, Nitter-Hauge S, Ueland T, Lien E, Froland SS, Aukrust P: Immunomodulating therapy with intravenous immunoglobulin in patients with chronic heart failure. Circulation. 2001, 103: 220-225.View ArticlePubMedGoogle Scholar
- Nishio R, Matsumori A, Shioi T, Ishida H, Sasayama S: Treatment of experimental viral myocarditis with interleukin-10. Circulation. 1999, 100: 1102-1108.View ArticlePubMedGoogle Scholar
- Shito M, Wakabayashi G, Ueda M, Shimazu M, Shirasugi N, Endo M, Mukai M, Kitajima M: Interleukin 1 receptor blockade reduces tumor necrosis factor production, tissue injury, and mortality after hepatic ischemia-reperfusion in the rat. Transplantation. 1997, 63: 143-148.View ArticlePubMedGoogle Scholar
- Damas JK, Gullestad L, Aass H, Simonsen S, Fjeld JG, Wikeby L, Ueland T, Eiken HG, Froland SS, Aukrust P: Enhanced gene expression of chemokines and their corresponding receptors in mononuclear blood cells in chronic heart failure-modulatory effects of intravenous immunoglobulin. J Am Coll Cardiol. 2001, 38: 187-193.View ArticlePubMedGoogle Scholar
- Kadokami T, McTiernan CF, Kubota T, Frye CS, Bounoutas GS, Robbins PD, Watkins SC, Feldman AM: Effects of soluble TNF receptor treatment on lipopolysaccaride-induced myocardial cytokine expression. Am J Physiol. 2001, 280: H2281-H2291.Google Scholar
- Louis A, Cleland JG, Crabbe S, Ford S, Thackray S, Houghton T, Clark A: Clinical trials update. Eur J Heart Fail. 2001, 3: 381-387.View ArticlePubMedGoogle Scholar
- Ballow M: Mechanisms of action of intravenous immune serum globulin in autoimmune and inflammatory diseases. J Allergy Clin Immunol. 1997, 100: 151-157.View ArticlePubMedGoogle Scholar
- Mobini N, Sarela A, Ahmed AR: Intravenous immunoglobins in the therapy of autoimmune and systemic inflammatory disorders. Ann Allergy Asthma Immunol. 1995, 74: 107-116.Google Scholar
- McNamara DM, Rosenblum WD, Janosko KM, Trost MK, Villaneuva FS, Demetris AJ, Murali S, Feldman AM: Intravenous immune globulin in the therapy of myocarditis and acute cardiomyopathy. Circulation. 1997, 95: 2476-2478.View ArticlePubMedGoogle Scholar
- Bozkurt B, Villaneuva FS, Holubkov R, Tokarczyk T, Alvarez RJ, MacGowan GA, Murali S, Rosenblum WD, Feldman AM, McNamara DM: Intravenous immune globulin in the therapy of peripartum cardiomyopathy. J Am Coll Cardiol. 1999, 34: 177-180.View ArticlePubMedGoogle Scholar
- McNamara DM, Holubkov R, Starling RC, Dec GW, Loh E, Torre-Amione G, Gass A, Janosko K, Tokarczyk T, Kessler P, Mann DL, Feldman AM: Controlled trial of intravenous immune globulin in recent-onset dilated cardiomyopathy. Circulation. 2001, 103: 2254-2259.View ArticlePubMedGoogle Scholar
- Wolf HM, Eibl MM: Immunomodulatory effect of immunoglobulins. Clin Exp Rheumatol. 1996, 14(suppl 15): S17-S25.Google Scholar
- Mann DL: Autoimmunity, immunoglobulin adsorption and dilated cardiomyopathy: has the time come for randomized clinical trials. J Am Coll Cardiol. 2001, 38: 184-186.View ArticlePubMedGoogle Scholar
- Schimke I, Muller J, Priem F, Kruse I, Schon B, Stein J, Kunze R, Wallukat G, Hetzer R: Decreased oxidative stress in patients with idiopathic dilated cardiomyopathy one year after immunoglobulin adsorption. J Am Coll Cardiol. 2001, 38: 178-183.View ArticlePubMedGoogle Scholar
- Staudt A, Schaper F, Stangl V, Plagemann A, Bohm M, Merkel K, Wallukat G, Wernecke KD, Stangl K, Baumann G, Felix SB: Immunohistological changes in dilated cardiomyopathy induced by immunoadsorption therapy and subsequent immunoglobulin substitution. Circulation. 2001, 103: 2681-2686.View ArticlePubMedGoogle Scholar