Castillo Rodrigo L, Farías Jorge, Sandoval Cristian, González-Candia Alejandro, Figueroa Esteban, Quezada Mauricio, Cruz Gonzalo, Llanos Paola, Jorquera Gonzalo, Kostin Sawa, Carrasco Rodrigo
Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago 7500922, Chile.
Unidad de Paciente Crítico, Hospital del Salvador, Santiago 7500922, Chile.
Antioxidants (Basel). 2024 Nov 14;13(11):1388. doi: 10.3390/antiox13111388.
In heart failure (HF) patients undergoing cardiac surgery, an increased activity of mechanisms related to cardiac remodeling may determine a higher risk of postoperative atrial fibrillation (POAF). Given that atrial fibrillation (AF) has a negative impact on the course and management of HF, including the need for anticoagulation therapy, identifying the factors associated with AF occurrence after cardiac surgery is crucial for the prognosis of these patients. POAF is thought to occur when various clinical and biochemical triggers act on susceptible cardiac tissue (first hit), with oxidative stress and inflammation during cardiopulmonary bypass (CPB) surgery being potential contributing factors (second hit). However, the molecular mechanisms involved in these processes remain poorly characterized. Recent research has shown that patients who later develop POAF often have pre-existing abnormalities in calcium handling and activation of NLRP3-inflammasome signaling in their atrial cardiomyocytes. These molecular changes may make cardiomyocytes more susceptible to spontaneous Ca2+-releases and subsequent arrhythmias, particularly when exposed to inflammatory mediators. Additionally, some clinical studies have linked POAF with elevated preoperative inflammatory markers, but there is a need for further research in order to better understand the impact of CPB surgery on local and systemic inflammation. This knowledge would make it possible to determine whether patients susceptible to POAF have pre-existing inflammatory conditions or cellular electrophysiological factors that make them more prone to developing AF and cardiac remodeling. In this context, the NLRP3 inflammasome, expressed in cardiomyocytes and cardiac fibroblasts, has been identified as playing a key role in the development of HF and AF, making patients with pre-existing HF with reduced ejection fraction (HFrEF) the focus of several clinical studies with interventions that act at this level. On the other hand, HFpEF has been linked to metabolic and non-ischemic risk factors, but more research is needed to better characterize the myocardial remodeling events associated with HFpEF. Therefore, since ventricular remodeling may differ between HFrEF and HFpEF, it is necessary to perform studies in both groups of patients due to their pathophysiological variations. Clinical evidence has shown that pharmacological therapies that are effective for HFrEF may not provide the same anti-remodeling benefits in HFpEF patients, particularly compared to traditional adrenergic and renin-angiotensin-aldosterone system inhibitors. On the other hand, there is growing interest in medications with pleiotropic or antioxidant/anti-inflammatory effects, such as sodium-glucose cotransporter 2 inhibitors (SGLT-2is). These drugs may offer anti-remodeling effects in both HFrEF and HFpEF by inhibiting pro-inflammatory, pro-oxidant, and NLRP3 signaling pathways and their mediators. The anti-inflammatory, antioxidant, and anti-remodeling effects of SGLT-2 i have progressively expanded from HFrEF and HFpEF to other forms of cardiac remodeling. However, these advances in research have not yet encompassed POAF despite its associations with inflammation, oxidative stress, and remodeling. Currently, the direct or indirect effects of NLRP3-dependent pathway inhibition on the occurrence of POAF have not been clinically assessed. However, given that NLRP3 pathway inhibition may also indirectly affect other pathways, such as inhibition of NF-kappaB or inhibition of matrix synthesis, which are strongly linked to POAF and cardiac remodeling, it is reasonable to hypothesize that this type of intervention could play a role in preventing these events.
在接受心脏手术的心力衰竭(HF)患者中,与心脏重塑相关的机制活性增加可能会导致术后心房颤动(POAF)的风险升高。鉴于心房颤动(AF)会对HF的病程和管理产生负面影响,包括需要进行抗凝治疗,因此识别心脏手术后与AF发生相关的因素对于这些患者的预后至关重要。POAF被认为是在各种临床和生化触发因素作用于易感性心脏组织(首次打击)时发生的,体外循环(CPB)手术期间的氧化应激和炎症是潜在的促成因素(二次打击)。然而,这些过程中涉及的分子机制仍未得到充分表征。最近的研究表明,后来发生POAF的患者通常在其心房心肌细胞中存在钙处理和NLRP3炎性小体信号激活的既往异常。这些分子变化可能使心肌细胞更容易发生自发性Ca2+释放和随后的心律失常,特别是在暴露于炎症介质时。此外,一些临床研究已将POAF与术前炎症标志物升高联系起来,但为了更好地了解CPB手术对局部和全身炎症的影响,仍需要进一步研究。这些知识将有助于确定易患POAF的患者是否存在既往炎症状态或细胞电生理因素,使他们更容易发生AF和心脏重塑。在这种背景下,在心肌细胞和心脏成纤维细胞中表达的NLRP3炎性小体已被确定在HF和AF的发展中起关键作用,这使得射血分数降低的既往HF(HFrEF)患者成为多项在此水平进行干预的临床研究的重点。另一方面,HFpEF与代谢和非缺血性危险因素有关,但需要更多研究来更好地表征与HFpEF相关的心肌重塑事件。因此,由于HFrEF和HFpEF之间的心室重塑可能不同,鉴于它们的病理生理差异,有必要在两组患者中进行研究。临床证据表明,对HFrEF有效的药物治疗可能不会在HFpEF患者中提供相同的抗重塑益处,特别是与传统的肾上腺素能和肾素-血管紧张素-醛固酮系统抑制剂相比。另一方面,人们对具有多效性或抗氧化/抗炎作用的药物,如钠-葡萄糖协同转运蛋白2抑制剂(SGLT-2is)的兴趣日益增加。这些药物可能通过抑制促炎、促氧化和NLRP3信号通路及其介质,在HFrEF和HFpEF中均提供抗重塑作用。SGLT-2i的抗炎、抗氧化和抗重塑作用已逐渐从HFrEF和HFpEF扩展到其他形式的心脏重塑。然而,尽管POAF与炎症、氧化应激和重塑有关,但这些研究进展尚未涵盖POAF。目前,NLRP3依赖性途径抑制对POAF发生的直接或间接影响尚未进行临床评估。然而,鉴于NLRP3途径抑制也可能间接影响其他途径,如抑制NF-κB或抑制基质合成,而这些途径与POAF和心脏重塑密切相关,因此合理推测这种类型的干预可能在预防这些事件中发挥作用。
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