Donate Help Contact The AHA Sign In Home
American Heart Association
Circulation
Search: search_blue_button Advanced Search
Circulation. 2000;101:2518-2525

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrowRequest Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kubota, T.
Right arrow Articles by Feldman, A. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kubota, T.
Right arrow Articles by Feldman, A. M.
Right arrowPubmed/NCBI databases
*Substance via MeSH
Medline Plus Health Information
*Cardiomyopathy
Related Collections
Right arrow Growth factors/cytokines
Right arrow Heart failure - basic studies
Right arrow Gene therapy

(Circulation. 2000;101:2518.)
© 2000 American Heart Association, Inc.


Basic Science Reports

Soluble Tumor Necrosis Factor Receptor Abrogates Myocardial Inflammation but Not Hypertrophy in Cytokine-Induced Cardiomyopathy

Toru Kubota, MD, PhD; George S. Bounoutas, MS; Masayuki Miyagishima, MD; Toshiaki Kadokami, MD, PhD; Virginia J. Sanders, PhD; Christina Bruton, MS; Paul D. Robbins, PhD; Charles F. McTiernan, PhD; Arthur M. Feldman, MD, PhD

From the Cardiovascular Institute (T. Kubota, G.S.B., T. Kadokami, C.F.M., A.M.F.), Department of Surgery (M.M.), Division of Neuropathology (V.J.S.), and Department of Molecular Genetics and Biochemistry (C.B., P.D.R.), University of Pittsburgh Medical Center, Pittsburgh, Pa.

Correspondence to Arthur M. Feldman, MD, PhD, 200 Lothrop St, S 572 Scaife Hall, Pittsburgh, PA 15213. E-mail feldmanam{at}msx.upmc.edu


*    Abstract
up arrowTop
*Abstract
down arrowIntroduction
down arrowMethods
down arrowResults
down arrowDiscussion
down arrowReferences
 
Background—Transgenic mice with cardiac-specific overexpression of tumor necrosis factor (TNF)-{alpha} develop dilated cardiomyopathy. The present study was designed to evaluate therapeutic effects of adenovirus-mediated neutralization of TNF-{alpha} on this model.

Methods and Results—An adenovirus encoding the 55-kDa TNF receptor–IgG fusion protein (AdTNFRI) was injected intravenously into 6-week-old transgenic mice, which resulted in high levels of TNFRI in both plasma and myocardium. AdTNFRI did not reverse cardiomegaly but abrogated myocardial inflammation. Furthermore, AdTNFRI blocked the myocardial expression of intercellular adhesion molecule-1 and downstream cytokines, including interleukin-1ß and monocyte chemotactic protein-1. Downregulation of {alpha}-myosin heavy chain was restored by the treatment, whereas upregulation of ß-myosin heavy chain was not reversed. In contrast, the downregulation of sarcoplasmic reticulum Ca2+-ATPase and phospholamban was normalized by AdTNFRI. Echocardiographic measurements showed that left ventricular end-systolic diameter was significantly larger in transgenic mice than in control mice, and this increase was reversed by the AdTNFRI treatment. However, left ventricular wall thickening was not reversed.

Conclusions—These results suggest that anti-TNF therapy may hold promise in the treatment of end-stage heart failure.


Key Words: viruses • genes • hormones


*    Introduction
up arrowTop
up arrowAbstract
*Introduction
down arrowMethods
down arrowResults
down arrowDiscussion
down arrowReferences
 
Tumor necrosis factor (TNF)-{alpha} is a proinflammatory cytokine with pleiotropic biological effects.1 Elevated plasma levels of TNF-{alpha} occur in a variety of cardiovascular diseases, including acute myocarditis, cardiac allograft rejection, myocardial infarction, and congestive heart failure (see review in Reference 2 ). Recent studies demonstrated that the heart itself can produce TNF-{alpha} in these disorders.3 To investigate the pathophysiological importance of myocardial production of TNF-{alpha}, we created 2 lines of transgenic mice that overexpress TNF-{alpha} in the heart under the control of {alpha}-myosin heavy chain (MHC) promoter.4 5 When TNF-{alpha} was robustly overexpressed, all mice developed severe lymphohistiocytic myocarditis and died in the neonatal period.4 When TNF-{alpha} overexpression was more modest, most mice survived the neonatal period; however, this line displayed a 6-month mortality of nearly 25%.5 Transgenic mice developed ventricular hypertrophy and dilatation, interstitial infiltrates and fibrosis, attenuation of adrenergic responsiveness, reexpression of atrial natriuretic factor (ANF) in the ventricle, and overt congestive heart failure.

Suppression of TNF-{alpha} bioactivity ameliorates the severity of myocarditis induced by injection of myosin6 or encephalomyocarditis virus.7 Furthermore, soluble TNF-binding proteins reverse the negative inotropic effects of TNF-{alpha} in vitro.8 The present study was undertaken to assess the effects of TNF-{alpha} suppression in mice having myocardial inflammation secondary to TNF-{alpha} overexpression using a replication-deficient recombinant adenovirus encoding an extracellular domain of human 55-kDa TNF receptor coupled with a mouse IgG heavy chain (AdTNFRI).9


*    Methods
up arrowTop
up arrowAbstract
up arrowIntroduction
*Methods
down arrowResults
down arrowDiscussion
down arrowReferences
 
Animals
Previously characterized transgenic mice (TNF1.6)5 were used under protocols approved by the Institutional Animal Care and Use Committee, University of Pittsburgh.

Adenoviruses
A replication-deficient recombinant adenovirus (AdTNFRI)9 encoding the extracellular domain of the human 55-kDa TNF receptor coupled with a mouse IgG heavy chain9 was generously provided by Dr Bruce Beutler, University of Texas Southwestern Medical Center, Dallas. An adenovirus encoding LacZ (AdLacZ) served as a control. Viruses were propagated in 293 cells and purified as previously described.9 The virus titer was equal to OD260 divided by 9.09x10-13 (in particles/mL). A hundred particles were assumed to be 1 pfu.

Experimental Design
Six-week-old TNF1.6 transgenic mice were injected through the retro-orbital venous plexi with 109 pfu of adenovirus and were euthanized for analysis 2 or 6 weeks later. After determination of body and ventricular weights, excised ventricles were snap-frozen in liquid nitrogen for biochemical analysis or processed for histological analysis. Plasma was collected for assessment of soluble TNFRI. Hearts from age- and sex-matched transgenic (TNF1.6) or wild-type (FVB) mice served as untreated controls. An additional 3 groups of mice (wild type, untreated TNF1.6, and TNF1.6 treated with AdTNFRI for 2 weeks) were used for echocardiography.

Echocardiography
Echocardiographic studies were performed with an Acuson ultrasonograph system (Sequoia 512, Acuson). Mice were anesthetized10 and lightly secured in a shallow left lateral decubitus position. A 13.0-MHz transducer was applied to the left hemithorax. 2D targeted M-mode imaging was obtained from the short-axis view at the level of the largest left ventricular diameter.

M-mode measurements of left ventricular end-diastolic and end-systolic diameters and left ventricular anterior and posterior wall thickness were made by use of the leading-edge convention of the American Society of Echocardiography. Three to 5 beats were averaged for each measurement. End diastole was determined at the maximal left ventricular diastolic dimension, and end systole was taken at the peak of posterior wall motion. Heart rate was determined from 3 to 5 consecutive RR intervals. Left ventricular fractional shortening (%) was calculated as LVFS (%)=[(LVEDD-LVESD)/LVEDD]x100, where LVEDD and LVESD indicate left ventricular end-diastolic and end-systolic diameters, respectively.

Quantification of Myocarditis
Myocardial infiltration was quantified in hematoxylin and eosin–stained sections by determination of nuclear density (nuclei/mm2). Because it is difficult to differentiate inflammatory cells from myocytes and/or fibroblasts, all nuclei were included. In each animal, 6 independent high-power fields (0.233x0.312 mm; 0.0729-mm2 area) were analyzed and averaged by investigators blinded to the treatment group.

RNase Protection
Total RNA was extracted from frozen tissues as described.4 5 RNase protection assays (RPAs) were performed according to the manufacturer’s protocol (RiboQuant, PharMingen; template sets mCK-1b, mCK-2b, mCK-3b, and mCK-5) with 5 µg of total RNA. After RNAase digestion, protected probes were resolved on denaturing polyacrylamide gels and quantified by PhosphoImager (ImageQuant software, Molecular Dynamics). The value of each hybridized probe was normalized to that of GAPDH included in each template set as an internal control.

Slot Blot
Total RNA (2.5 µg each sample) denatured with formaldehyde was vacuum-blotted onto nitrocellulose. Hybridization probes were prepared from oligomers complementary to murine {alpha}- or ß-MHC11 and other probes (18S ribosomal RNA, ANF, sarcoplasmic/endoplasmic reticulum Ca2+-ATPase [SERCA], and phospholamban) as previously described.5 12 MHC oligomer probes were hybridized (55°C in 4x SSC, 5x Denhardt’s, 0.1% SDS, 0.05% sodium pyrophosphate, tRNA 20 µg/mL, 32P-labeled oligomer 3 ng/mL), washed (2x SSC–0.1% SDS at 60°C), and exposed to a storage phosphor screen, and radioactive images were quantified as described above. Filters were rehybridized with the 18S oligonucleotide, reexposed, and quantified.5 12 Hybridization signals were normalized to that of the 18S probe and in turn normalized to the mean of the control samples.

Reverse Transcription–Polymerase Chain Reaction
Reverse transcription–polymerase chain reaction (RT-PCR) reactions were performed as described.4 5 12 Oligonucleotide primer pairs included (1) intercellular adhesion molecule-1 (ICAM-1) sense primer corresponding to base pairs 1112 to 1135 and antisense primer complementary to base pairs 1525 to 1547 (GenBank Accession No. X52264) and (2) total TNF-{alpha} (both transgene and endogenous gene) sense primer corresponding to base pairs 164 to 187 and antisense primer complementary to base pairs 833 to 855 (GenBank accession No. M13049). PCR was performed for 30 cycles (94°C for 60 seconds, 55°C for 30 seconds, and 72°C for 60 seconds), and products were visualized on 2% agarose gels by ethidium bromide staining.

Enzyme-Linked Immunosorbent Assay
Cytokine protein levels were assessed by ELISA (mouse TNF-{alpha}, mouse interleukin [IL]-1ß, mouse monocyte chemotactic protein [MCP]-1, and human TNFRI, Quantikine, R&D Systems). Plasma samples (assayed in duplicate) were measured at a dilution of 10-1 to 10-6. Cytokines in the myocardium were measured as previously reported,4 5 with 100 µg of protein for TNF-{alpha}, IL-1ß, and MCP-1 and 1 µg for TNFRI. Standard reference cytokines were provided by the manufacturer. Values are reported as pg/mg or ng/mg protein. Because this study used a different vendor for the TNF-{alpha} ELISA kits, the values of TNF-{alpha} protein in the myocardium were substantially lower than those previously reported.5 This is attributable to differences in the standard reference cytokines as well as a substantially lower background of TNF-{alpha} in tissue homogenates.

Immunohistochemistry
Mouse hearts were fixed in ice-cold 2% paraformaldehyde, immersed in ice-cold 30% sucrose, and flash-frozen in OCT (Miles) medium with isopentane cooled by liquid nitrogen. Blocks were cut at 10 µm, and sections were mounted, immersion-fixed in acetone, rinsed in PBS, and treated for 30 minutes with 5% normal rabbit serum. Primary antibodies used were polyclonal goat anti-murine TNF-{alpha} (1:100, Santa Cruz Biotechnology), goat anti-murine IL-1ß, and goat anti-murine MCP-1 (both 1:100, R&D Systems). Samples were treated with primary antibody (24 hours at 4°C), rinsed with PBS, treated (2 hours) with multilink biotinylated anti-goat secondary antibody (1:4 dilution, Biogenex Laboratories), rinsed in PBS, and treated with avidin-biotin complex (45 minutes; Vector Laboratories). Reactions were visualized with 3-amino-9-ethyl-carbazole in 0.1 mol/L acetate buffer, pH 5.2. Sections were weakly counterstained with Mayer’s hematoxylin.

Statistics
Results are presented as mean±SD. Statistical comparisons were performed by ANOVA with Student-Newman-Keuls post hoc test. Differences were considered significant at a value of P<0.05.


*    Results
up arrowTop
up arrowAbstract
up arrowIntroduction
up arrowMethods
*Results
down arrowDiscussion
down arrowReferences
 
Production of TNF Receptor Fusion Protein
Pilot studies in male wild-type mice determined that intravenous injections of 109 and 108 pfu of AdTNFRI produced a substantial amount of TNFRI in plasma after 1 week, whereas intraperitoneal injection did not (Figure 1Down). Plasma levels of TNFRI declined thereafter but remained in the µg/mL range for as long as 6 weeks. Attempts to reinoculate mice to boost TNFRI levels were unsuccessful (data not shown). Subsequent studies used a single intravenous inoculation with 109 pfu of adenovirus.



View larger version (18K):
[in this window]
[in a new window]
 
Figure 1. Plasma levels of TNFRI after inoculation with AdTNFRI. Values are mean±SD (n=4 to 7).

Six-week-old female transgenic (TNF1.6) mice were injected with 109 pfu of either AdTNFRI or AdLacZ and euthanized for analysis after an additional 2 or 6 weeks. Age-matched transgenic or wild-type mice were euthanized as untreated controls. As in wild-type mice, AdTNFRI produced substantial amounts of soluble TNFRI in plasma (96.2±61.0 µg/mL) as well as in myocardium (82.5±21.5 ng/mg protein) after 2 weeks. Because the amounts of TNF-{alpha} protein in the myocardium of AdTNFRI-treated transgenic mice was 419±137 pg/mg protein, there was a large excess ({approx}200-fold) of TNFRI protein in the heart.

Cardiomegaly
Transgenic mice presented significant cardiomegaly, as indicated by the increased ventricular weight/body weight ratio, and 2 weeks of anti-TNF treatment was insufficient to ameliorate cardiomegaly (Table 1Down). Furthermore, cardiomegaly remained unchanged 6 weeks after injection of AdTNFRI, although plasma levels of TNFRI remained high (32.3±8.8 µg/mL).


View this table:
[in this window]
[in a new window]
 
Table 1. Body and Ventricular Weights of Adenovirus-Treated Mice

Myocardial Inflammation
Eight-week-old untreated transgenic mice presented a diffuse interstitial infiltration in the myocardium consisting of mostly histiocytes with some lymphocytes (Figure 2Down). Two weeks after treatment with AdTNFRI, interstitial infiltration was substantially reduced, as evidenced by nuclear density (Figure 3Down), an effect not observed by treatment with AdLacZ. Myocardial infiltrates remained suppressed for >=6 weeks (data not shown), reflecting the persistent elevation in plasma levels of TNFRI.



View larger version (76K):
[in this window]
[in a new window]
 
Figure 2. Hematoxylin-eosin staining of myocardium: (A) wild-type mouse, (B) transgenic mouse, (C) transgenic mouse 2 weeks after inoculation with AdLacZ, and (D) transgenic mouse 2 weeks after inoculation with AdTNFRI.



View larger version (18K):
[in this window]
[in a new window]
 
Figure 3. Nuclear density of myocardium: wild-type mice (WT), transgenic mice (TG), transgenic mice 2 weeks after inoculation with AdLacZ (TG+AdLacZ), and transgenic mice 2 weeks after inoculation with AdTNFRI (TG+AdTNFRI). Values are mean±SD (n=5 to 6). *P<0.05 vs WT, {dagger}P<0.05 TG+AdTNFRI vs TG+AdLacZ.

To assess the potential mechanism by which TNFRI overexpression reduces myocardial infiltration, we analyzed expression of ICAM-1 by RT-PCR in wild-type mice, TNF1.6 mice, and TNF1.6 mice 2 weeks after inoculation with AdTNFRI. RT-PCR analysis demonstrated increased ICAM-1 transcript levels in TNF1.6 mice, which were markedly reduced in animals treated with AdTNFRI (Figure 4Down). However, TNF-{alpha} transcript levels (both transgene-driven and endogenous gene transcripts) remained elevated in TNF1.6 mice regardless of TNF-soluble-receptor therapy, consistent with RPA analyses (see below, Figure 5Down).



View larger version (72K):
[in this window]
[in a new window]
 
Figure 4. RT-PCR assessment of ICAM-1 expression (top) in ventricular RNA isolated from wild-type (WT), TNF-{alpha} transgenic (TNF1.6), and TNF-{alpha} transgenic mice 2 weeks after inoculation with AdTNFRI (TNF1.6+AdTNFRI). RT-PCR assessment of total (endogenous and transgene-driven) TNF-{alpha} expression (bottom) in same animals. M indicates DNA marker; size is in base pairs.



View larger version (58K):
[in this window]
[in a new window]
 
Figure 5. Representative images of multiprobe RPA: (A) mCK-3b, (B) mCK-2b, (C) mCK-1b, and (D) mCK-5. Animal group abbreviations as in Figure 3Up. LT indicates lymphotoxin; IL, interleukin; IFN, interferon; TGF, transforming growth factor; MIF, macrophage inflammatory protein; IP, interferon-inducible protein; and TCA, T-cell activation gene.

Cytokine Expression
Because TNF-{alpha} can induce the expression of other proinflammatory cytokines and chemokines that contribute to TNF-{alpha}–induced pathophysiology,1 we examined the expression of additional cytokines by use of multiprobe RPAs. Representative images of RPAs are shown in Figure 5Up, and quantitative results are summarized in Table 2Down. Although overexpression of TNF-{alpha} induced a large number of cytokines, the induction of IL-1ß and MCP-1 was particularly robust. With the exception of transforming growth factor-ß induction, all of the changes in cytokine and chemokine expression evident in the TNF-{alpha} transgenic mice were reversed after 2 weeks of treatment with soluble TNF receptor.


View this table:
[in this window]
[in a new window]
 
Table 2. Expression of Cytokines in the Myocardium

To confirm that changes in mRNA reflected alterations at the protein level, we selected 3 cytokines for ELISA: TNF-{alpha}, IL-1ß, and MCP-1. IL-1ß was chosen because of its synergistic effects with TNF-{alpha}, as well as its independent effects on cardiomyocyte function and gene expression.12 13 MCP-1, a prominent signal for the accumulation of monocytes, is expressed in response to proinflammatory cytokines14 and may be an important mediator of myocardial infiltration.15 All 3 cytokine proteins were not found in wild-type mice but were abundant in the TNF-{alpha} transgenic mice (Figure 6Down). Two weeks of anti-TNF treatment abrogated the induction of IL-1ß and MCP-1 proteins, consistent with changes in the transcript levels. The induction of these downstream cytokines remained inhibited 6 weeks after treatment (data not shown). In contrast, despite a reversal of myocardial infiltration and a reduction in other cytokine expression, anti-TNF treatment actually increased the immunodetectable levels of TNF-{alpha} in myocardium >2-fold.



View larger version (9K):
[in this window]
[in a new window]
 
Figure 6. Protein levels of cytokines in myocardium: (A) TNF-{alpha}, (B) IL-1ß, and (C) MCP-1. Abbreviations as in Figure 3Up. Values are mean±SD (n=6). *P<0.05 vs WT, {dagger}P<0.05 TG+AdTNFRI vs TG+AdLacZ.

Immunohistochemical stains were performed to identify the cell source of these cytokines (Figure 7Down). Anti–TNF-{alpha} resulted in diffuse background staining with some positive-stained interstitial cells, suggesting that both cardiomyocytes and infiltrating cells produced TNF-{alpha} in the myocardium. In contrast, the staining for IL-1ß and MCP-1 was confined to interstitial cells, including inflammatory infiltrates and fibroblasts.



View larger version (112K):
[in this window]
[in a new window]
 
Figure 7. Immunohistochemical staining of myocardium of transgenic mice for (A) TNF-{alpha}, (B) IL-1ß, and (C) MCP-1. Arrows indicate positive-stained interstitial cells.

Cardiac-Specific Gene Expression
Figure 8Down summarizes changes in the expression of cardiac-specific genes in TNF1.6 mice. Relative to wild-type untreated controls, {alpha}-MHC, SERCA, and phospholamban transcripts were downregulated, whereas ß-MHC and ANF were upregulated, in the ventricles of transgenic mice. Treatment with AdLacZ had no significant effects on the expression of these genes, whereas anti-TNF treatment with AdTNFRI reversed changes in {alpha}-MHC, SERCA, and phospholamban, partially reversed ANF, and had no effect on ß-MHC expression. Gene transcript levels after the 6-week treatment were similar to those observed after the 2-week treatment. {alpha}-MHC, SERCA, and phospholamban transcripts were restored to wild-type levels (0.89±0.11, 0.95±0.25, and 0.96±0.20, n=4, respectively), whereas ß-MHC and ANF transcripts remained elevated (4.21±0.80 and 4.00±1.68, n=4). The trend toward further reduction in ANF transcripts was not statistically significant.



View larger version (20K):
[in this window]
[in a new window]
 
Figure 8. Transcript levels of cardiac-specific genes: (A) {alpha}-MHC, (B) ß-MHC, (C) ANF, (D) SERCA, and (E) phospholamban. Values are mean±SD (n=6 to 12). *P<0.05 vs WT, {dagger}P<0.05 TG+AdTNFRI vs TG+AdLacZ.

Anti-TNF Therapy and Cardiac Function
Examples of M-mode echocardiographic measurements in TNF-{alpha} transgenic mice with or without AdTNFRI treatment and wild-type controls are presented in Figure 9Down and quantitative results in Table 3Down. At this age, the left ventricular fractional shortening in transgenic mice was comparable to that in controls, whereas left ventricular end-systolic diameter was significantly larger in transgenic mice than in control mice, suggesting a latent left ventricular dysfunction in young transgenic mice. This increase in the diameter was reversed by the AdTNFRI treatment. In contrast, significant left ventricular wall thickening in the transgenic mice was not reversed after the TNF neutralizing therapy.



View larger version (91K):
[in this window]
[in a new window]
 
Figure 9. M-mode echocardiography from (A) wild-type controls, (B) TNF-{alpha} transgenic mice, and (C) transgenic mice with TNFRI treatment. In TNF-{alpha} transgenic mice, left ventricular enlargement but not left ventricular wall thickening was reversed by TNFRI treatment.


View this table:
[in this window]
[in a new window]
 
Table 3. Echocardiographic Measurements


*    Discussion
up arrowTop
up arrowAbstract
up arrowIntroduction
up arrowMethods
up arrowResults
*Discussion
down arrowReferences
 
Soluble TNF receptor was achieved by intravenous injection with a recombinant adenovirus encoding a fusion protein containing the extracellular domain of human TNFRI (p55) coupled with a mouse IgG heavy chain.9 The virus transfects the liver, which then produces soluble TNFRI. A sustained secretion of TNFRI into the plasma permeates the extracellular space of multiple organs, including the myocardium.16 The principal limitation of using recombinant adenovirus is that endogenous immunological activity reduces AdTNFRI expression and significant levels of TNFRI cannot be found after several months. However, beneficial biological effects of TNFRI in mice overexpressing proinflammatory cytokines can be clearly demonstrated within 2 weeks of therapy and persist through 6 weeks.

Transgenic mice with cardiac-specific overexpression of TNF-{alpha} present lymphohistiocytic myocarditis, cardiomegaly, cardiac dysfunction, and congestive heart failure.5 Whereas some of the phenotypic changes that characterize the TNF-{alpha} transgenic mice could be attributed to TNF-{alpha} alone, the TNF-{alpha} induction of "downstream" cytokines and chemokines may contribute to TNF-{alpha}–induced pathophysiology.1 Indeed, overexpression of TNF-{alpha} induced the expression of a large number of cytokines and chemokines. Nearly all of the induced cytokines showed reversal of expression after AdTNFRI treatment, suggesting their activation downstream of TNF-{alpha}.

Both transcript and protein levels of TNF-{alpha}, IL-1ß, and MCP-1 were increased in the myocardium of transgenic mice and reversed by anti-TNF treatment. Immunohistochemical analysis suggested that IL-1ß and MCP-1 were produced predominantly by nonmyocytes. In contrast, TNF-{alpha} expression was found in both myocytes and nonmyocytes, and the protein level, elevated in transgenic animals, was further increased after the treatment with AdTNFRI. Because TNF-{alpha} transcripts were not significantly higher in AdTNFRI-treated mice, the increase in TNF-{alpha} protein is unlikely to arise from enhanced transcriptional activity of the TNF-{alpha} genes. More likely, although TNF-{alpha} loses its bioactivity when bound by TNFRI, it may also gain stability as soluble TNF receptors stabilize TNF-{alpha} protein despite blockade of its bioactivity.17 Because the ELISA measures both receptor-bound and free TNF-{alpha}, the major contribution to the increase might be due to soluble receptor-bound TNF-{alpha}. Regardless of increased TNF-{alpha} protein in AdTNFRI-treated mice, the biological effects of TNF-{alpha} were attenuated, as shown by the abrogation of myocarditis and expression of downstream cytokines.

Although anti-TNF treatment with AdTNFRI abrogated the expression of inflammatory mediators and the development of interstitial infiltrates, treatment had no effect on ventricular hypertrophy. Furthermore, treatment had no effect on the increased ventricular expression of ß-MHC in TNF-{alpha} transgenic mice and only a partial suppression of the enhanced ANF expression. Because upregulation of ß-MHC expression is an integral part of the development of myocardial hypertrophy,18 the failure of soluble TNF receptor to attenuate either ß-MHC expression or ventricular hypertrophy is internally consistent. Because {alpha}- and ß-MHC are thought to be regulated reciprocally, it is of interest that anti-TNF treatment reversed the TNF-{alpha}–induced downregulation of {alpha}-MHC but not the upregulation of ß-MHC. Gupta and Zak19 demonstrated, however, that isoform shifts in the pressure-overload–induced hypertrophy model were not temporally related; {alpha}-MHC expression was normalized within 2 weeks after the removal of the aortic band, whereas ß-MHC expression required 7 weeks to be normalized.

Although we cannot exclude the possibility that a more prolonged exposure to anti-TNF therapy will reverse hypertrophy and normalize ß-MHC upregulation, these results suggest that the hypertrophic process may persist regardless of apparent neutralization of myocardial TNF-{alpha}. Indeed, the hypertrophic program may be initiated early in the development of heart failure and be self-sustaining and thus unresponsive to anti–TNF-{alpha} intervention at 6 weeks of age. Alternatively, a very low level of biologically active TNF-{alpha} may persist despite therapy with TNFRI, allowing continued stimulation of a hypertrophic signaling pathway.

{alpha}-MHC, SERCA, and phospholamban transcripts are downregulated in end-stage heart failure in both human20 21 and animal22 models. IL-1ß inhibits expression of these genes in cultured neonatal cardiomyocytes,12 and both IL-1ß and TNF-{alpha} alter cardiomyocyte contractile activity.13 Thus, the observation that cardiac-specific overexpression of TNF-{alpha} and induction of IL-1ß is associated with downregulation of these genes is consistent with in vitro studies.

The potential utility of anti-TNF therapy in the management of congestive heart failure is currently an area of great interest.23 Infusion of a dimeric soluble TNF receptor has been shown to antagonize the negative inotropic effects of chronic TNF-{alpha} infusion in rats.24 This model is not accompanied by myocardial infiltrates or cardiac-specific overexpression of TNF-{alpha}, suggesting a beneficial role of TNF-{alpha} blockade in noninflammatory models of heart failure. However, the complete role of TNF-{alpha} in heart failure that does not arise as a consequence of TNF-{alpha} administration remains to be fully elucidated. Because anti-TNF therapies reduce the severity of autoimmune6 or virus-induced myocarditis,7 one might hypothesize that anti-TNF therapies would prove to be of benefit in cardiac inflammatory diseases. However, anti–TNF-{alpha} antibodies exacerbate the pathology in murine models of Chagas cardiomyopathy25 ; hence, the full utility of anti-TNF therapy in the regulation of inflammatory heart disease and heart failure remains promising yet incompletely explored. Additional information regarding the contribution of TNF-{alpha} to heart failure may come from ongoing investigations of the efficacy of soluble TNF receptor therapy in patients with chronic congestive heart failure.


*    Acknowledgments
 
This work was supported by NIH grant HL-60032-01. Dr Kubota is the recipient of a Japan Heart Foundation and Bayer Yakuhin Research Grant Abroad. Dr Kadokami is supported by the Bill Hilgrove Fellowship. The authors thank Tracey Barry for editorial and Carole Frye for technical assistance.

Received August 19, 1999; revision received December 15, 1999; accepted December 15, 1999.


*    References
up arrowTop
up arrowAbstract
up arrowIntroduction
up arrowMethods
up arrowResults
up arrowDiscussion
*References
 
1. Zhang M, Tracey KJ. Tumor necrosis factor. In: Thomson AW, ed. The Cytokine Handbook. 3rd ed. San Diego, Calif: Academic Press; 1998:517–548.

2. Meldrum DR, Cleveland JC Jr, Cain BS, et al. Increased myocardial tumor necrosis factor-alpha in a crystalloid-perfused model of cardiac ischemia-reperfusion injury. Ann Thorac Surg. 1998;65:439–443.[Abstract/Free Full Text]

3. Torre-Amione G, Kapadia S, Lee J, et al. Tumor necrosis factor-alpha and tumor necrosis factor receptors in the failing human heart. Circulation. 1996;93:704–711.[Abstract/Free Full Text]

4. Kubota T, McTiernan CF, Frye CS, et al. Cardiac-specific overexpression of tumor necrosis factor-alpha causes lethal myocarditis in transgenic mice. J Card Fail. 1997;3:117–124.[Medline] [Order article via Infotrieve]

5. Kubota T, McTiernan CF, Frye CS, et al. Dilated cardiomyopathy in transgenic mice with cardiac-specific overexpression of tumor necrosis factor-{alpha}. Circ Res. 1997;81:627–635.[Abstract/Free Full Text]

6. Smith SC, Allen PM. Neutralization of endogenous tumor necrosis factor ameliorates the severity of myosin-induced myocarditis. Circ Res. 1992;70:856–863.[Abstract/Free Full Text]

7. Yamada T, Matsumori A, Sasayama S. Therapeutic effect of anti–tumor necrosis factor-{alpha} antibody on the murine model of viral myocarditis induced by encephalomyocarditis virus. Circulation. 1994;89:846–851.[Abstract/Free Full Text]

8. Kapadia S, Torre-Amione G, Yokoyama T, et al. Soluble TNF binding proteins modulate the negative inotropic properties of TNF-alpha in vitro. Am J Physiol. 1995;268:H517–H525.[Abstract/Free Full Text]

9. Kolls J, Peppel K, Silva M, et al. Prolonged and effective blockade of tumor necrosis factor activity through adenovirus-mediated gene transfer. Proc Natl Acad Sci U S A. 1994;91:215–219.[Abstract/Free Full Text]

10. Kubota T, Mahler CM, McTiernan CF, et al. End-systolic pressure-dimension relationship of in situ mouse left ventricle. J Mol Cell Cardiol. 1998;30:357–363.[Medline] [Order article via Infotrieve]

11. Robbins J, Gulick J, Sanchez A, et al. Mouse embryonic stem cells express the cardiac myosin heavy chain genes during development in vitro. J Biol Chem. 1990;265:11905–11909.[Abstract/Free Full Text]

12. McTiernan CF, Lemster BH, Frye C, et al. Interleukin-1ß inhibits phospholamban gene expression in cultured cardiomyocytes. Circ Res. 1997;81:493–503.[Abstract/Free Full Text]

13. Gulick T, Chung MK, Pieper SJ, et al. Interleukin 1 and tumor necrosis factor inhibit cardiac myocyte beta-adrenergic responsiveness. Proc Natl Acad Sci U S A. 1989;86:6753–6757.[Abstract/Free Full Text]

14. Rollins BJ, Yoshimura T, Leonard EJ, et al. Cytokine-activated human endothelial cells synthesize and secrete a monocyte chemoattractant, MCP-1/JE. Am J Pathol. 1990;136:1229–1233.[Abstract]

15. Kolattukudy PE, Quach T, Bergese S, et al. Myocarditis induced by targeted expression of the MCP-1 gene in murine cardiac muscle. Am J Pathol. 1998;152:101–111.[Abstract]

16. Kolls JK, Lei D, Nelson S, et al. Adenovirus-mediated blockade of tumor necrosis factor in mice protects against endotoxic shock yet impairs pulmonary host defense. J Infect Dis. 1995;171:570–575.[Medline] [Order article via Infotrieve]

17. Mohler KM, Torrance DS, Smith CA, et al. Soluble tumor necrosis factor (TNF) receptors are effective therapeutic agents in lethal endotoxemia and function simultaneously as both TNF carriers and TNF antagonists. J Immunol. 1993;151:1548–1561.[Abstract]

18. Nadal-Ginard B, Mahdavi V. Molecular basis of cardiac performance: plasticity of the myocardium generated through protein isoform switches. J Clin Invest. 1989;84:1693–1700.

19. Gupta M, Zak R. Reversibility of load-induced changes in myosin heavy chain gene expression. Am J Physiol. 1992;262:R346–R349.[Abstract/Free Full Text]

20. Mercadier JJ, Lompre AM, Duc P, et al. Altered sarcoplasmic reticulum Ca2(+)-ATPase gene expression in the human ventricle during end-stage heart failure. J Clin Invest. 1990;85:305–309.

21. Feldman AM, Ray PE, Silan CM, et al. Selective gene expression in failing human heart: quantification of steady-state levels of messenger RNA in endomyocardial biopsies using the polymerase chain reaction. Circulation. 1991;83:1866–1872.[Abstract/Free Full Text]

22. Rockman HA, Ono S, Ross RS, et al. Molecular and physiological alterations in murine ventricular dysfunction. Proc Natl Acad Sci U S A. 1994;91:2694–2698.[Abstract/Free Full Text]

23. Deswal A, Bozkurt B, Seta Y, et al. Safety and efficacy of a soluble P75 tumor necrosis factor receptor (Enbrel, etanercept) in patients with advanced heart failure. Circulation. 1999;99:3224–3226.[Abstract/Free Full Text]

24. Bozkurt B, Kribbs SB, Clubb FJ Jr, et al. Pathophysiologically relevant concentrations of tumor necrosis factor-{alpha} promote progressive left ventricular dysfunction and remodeling in rats. Circulation. 1998;97:1382–1391.[Abstract/Free Full Text]

25. Lima EC, Garcia I, Vicentelli MH, et al. Evidence for a protective role of tumor necrosis factor in the acute phase of Trypanosoma cruzi infection in mice. Infect Immun. 1997;65:457–465.[Abstract]




This article has been cited by other articles:


Home page
Circ Heart FailHome page
R. D. Patten and M. R. Hall-Porter
Small Animal Models of Heart Failure: Development of Novel Therapies, Past and Present
Circ Heart Fail, March 1, 2009; 2(2): 138 - 144.
[Full Text] [PDF]


Home page
CirculationHome page
M. Andrassy, H. C. Volz, J. C. Igwe, B. Funke, S. N. Eichberger, Z. Kaya, S. Buss, F. Autschbach, S. T. Pleger, I. K. Lukic, et al.
High-Mobility Group Box-1 in Ischemia-Reperfusion Injury of the Heart
Circulation, June 24, 2008; 117(25): 3216 - 3226.
[Abstract] [Full Text] [PDF]


Home page
Am. J. Physiol. Heart Circ. Physiol.Home page
Y. Monden, T. Kubota, T. Inoue, T. Tsutsumi, S. Kawano, T. Ide, H. Tsutsui, and K. Sunagawa
Tumor necrosis factor-{alpha} is toxic via receptor 1 and protective via receptor 2 in a murine model of myocardial infarction
Am J Physiol Heart Circ Physiol, July 1, 2007; 293(1): H743 - H753.
[Abstract] [Full Text] [PDF]


Home page
Am. J. Physiol. Heart Circ. Physiol.Home page
M. Wang, T. Markel, P. Crisostomo, C. Herring, K. K. Meldrum, K. D. Lillemoe, and D. R. Meldrum
Deficiency of TNFR1 protects myocardium through SOCS3 and IL-6 but not p38 MAPK or IL-1beta
Am J Physiol Heart Circ Physiol, April 1, 2007; 292(4): H1694 - H1699.
[Abstract] [Full Text] [PDF]


Home page
Cardiovasc ResHome page
Y. Monden, T. Kubota, T. Tsutsumi, T. Inoue, S. Kawano, N. Kawamura, T. Ide, K. Egashira, H. Tsutsui, and K. Sunagawa
Soluble TNF receptors prevent apoptosis in infiltrating cells and promote ventricular rupture and remodeling after myocardial infarction
Cardiovasc Res, March 1, 2007; 73(4): 794 - 805.
[Abstract] [Full Text] [PDF]


Home page
Am. J. Physiol. Heart Circ. Physiol.Home page
K. Nishikawa, M. Yoshida, M. Kusuhara, N. Ishigami, K. Isoda, K. Miyazaki, and F. Ohsuzu
Left ventricular hypertrophy in mice with a cardiac-specific overexpression of interleukin-1
Am J Physiol Heart Circ Physiol, July 1, 2006; 291(1): H176 - H183.
[Abstract] [Full Text] [PDF]


Home page
Am. J. Clin. Nutr.Home page
S. S Schleithoff, A. Zittermann, G. Tenderich, H. K Berthold, P. Stehle, and R. Koerfer
Vitamin D supplementation improves cytokine profiles in patients with congestive heart failure: a double-blind, randomized, placebo-controlled trial.
Am. J. Clinical Nutrition, April 1, 2006; 83(4): 754 - 759.
[Abstract] [Full Text] [PDF]


Home page
Cardiovasc ResHome page
Y. Xu, I. A. Arenas, S. J. Armstrong, W. C. Plahta, H. Xu, and S. T. Davidge
Estrogen improves cardiac recovery after ischemia/reperfusion by decreasing tumor necrosis factor-{alpha}
Cardiovasc Res, March 1, 2006; 69(4): 836 - 844.
[Abstract] [Full Text] [PDF]


Home page
Am. J. Physiol. Heart Circ. Physiol.Home page
H. Matsusaka, M. Ikeuchi, S. Matsushima, T. Ide, T. Kubota, A. M. Feldman, A. Takeshita, K. Sunagawa, and H. Tsutsui
Selective disruption of MMP-2 gene exacerbates myocardial inflammation and dysfunction in mice with cytokine-induced cardiomyopathy
Am J Physiol Heart Circ Physiol, November 1, 2005; 289(5): H1858 - H1864.
[Abstract] [Full Text] [PDF]


Home page
Cardiovasc ResHome page
N. Kawamura, T. Kubota, S. Kawano, Y. Monden, A. M. Feldman, H. Tsutsui, A. Takeshita, and K. Sunagawa
Blockade of NF-{kappa}B improves cardiac function and survival without affecting inflammation in TNF-{alpha}-induced cardiomyopathy
Cardiovasc Res, June 1, 2005; 66(3): 520 - 529.
[Abstract] [Full Text] [PDF]


Home page
Eur Heart J SupplHome page
T. Bachetti, L. Comini, E. Pasini, and R. Ferrari
Anti-cytokine therapy in chronic heart failure: new approaches and unmet promises
Eur. Heart J. Suppl., November 1, 2004; 6(suppl_F): F16 - F21.
[Abstract] [Full Text] [PDF]


Home page
CirculationHome page
Y. Higuchi, C. F. McTiernan, C. B. Frye, B. S. McGowan, T. O. Chan, and A. M. Feldman
Tumor Necrosis Factor Receptors 1 and 2 Differentially Regulate Survival, Cardiac Dysfunction, and Remodeling in Transgenic Mice With Tumor Necrosis Factor-{alpha}-Induced Cardiomyopathy
Circulation, April 20, 2004; 109(15): 1892 - 1897.
[Abstract] [Full Text] [PDF]


Home page
J Am Coll CardiolHome page
T. Shiomi, H. Tsutsui, M. Ikeuchi, H. Matsusaka, S. Hayashidani, N. Suematsu, J. Wen, T. Kubota, and A. Takeshita
Streptozotocin-induced hyperglycemia exacerbates left ventricular remodeling and failure after experimental myocardial infarction
J. Am. Coll. Cardiol., July 2, 2003; 42(1): 165 - 172.
[Abstract] [Full Text] [PDF]


Home page
CirculationHome page
E. S. Chung, M. Packer, K. H. Lo, A. A. Fasanmade, and J. T. Willerson
Randomized, Double-Blind, Placebo-Controlled, Pilot Trial of Infliximab, a Chimeric Monoclonal Antibody to Tumor Necrosis Factor-{alpha}, in Patients With Moderate-to-Severe Heart Failure: Results of the Anti-TNF Therapy Against Congestive Heart failure (ATTACH) Trial
Circulation, July 1, 2003; 107(25): 3133 - 3140.
[Abstract] [Full Text] [PDF]


Home page
J. Biol. Chem.Home page
A. W. Ashton, G. M. Ware, D. K. Kaul, and J. A. Ware
Inhibition of Tumor Necrosis Factor alpha -mediated NFkappa B Activation and Leukocyte Adhesion, with Enhanced Endothelial Apoptosis, by G Protein-linked Receptor (TP) Ligands
J. Biol. Chem., March 28, 2003; 278(14): 11858 - 11866.
[Abstract] [Full Text] [PDF]


Home page
Pharmacol. Rev.Home page
J. H. Von der Thusen, J. Kuiper, T. J. C. Van Berkel, and E. A. L. Biessen
Interleukins in Atherosclerosis: Molecular Pathways and Therapeutic Potential
Pharmacol. Rev., March 1, 2003; 55(1): 133 - 166.
[Abstract] [Full Text] [PDF]


Home page
Am. J. Physiol. Heart Circ. Physiol.Home page
B. London, L. C. Baker, J. S. Lee, V. Shusterman, B.-R. Choi, T. Kubota, C. F. McTiernan, A. M. Feldman, and G. Salama
Calcium-dependent arrhythmias in transgenic mice with heart failure
Am J Physiol Heart Circ Physiol, February 1, 2003; 284(2): H431 - H441.
[Abstract] [Full Text] [PDF]


Home page
Am. J. Physiol. Heart Circ. Physiol.Home page
Y. Machida, T. Kubota, N. Kawamura, H. Funakoshi, T. Ide, H. Utsumi, Y. Y. Li, A. M. Feldman, H. Tsutsui, H. Shimokawa, et al.
Overexpression of tumor necrosis factor-alpha increases production of hydroxyl radical in murine myocardium
Am J Physiol Heart Circ Physiol, February 1, 2003; 284(2): H449 - H455.
[Abstract] [Full Text] [PDF]


Home page
HeartHome page
P A Henriksen and D E Newby
Therapeutic inhibition of tumour necrosis factor {alpha} in patients with heart failure: cooling an inflamed heart
Heart, January 1, 2003; 89(1): 14 - 18.
[Abstract] [Full Text] [PDF]


Home page
CirculationHome page
T. Shiomi, H. Tsutsui, S. Hayashidani, N. Suematsu, M. Ikeuchi, J. Wen, M. Ishibashi, T. Kubota, K. Egashira, and A. Takeshita
Pioglitazone, a Peroxisome Proliferator-Activated Receptor-{gamma} Agonist, Attenuates Left Ventricular Remodeling and Failure After Experimental Myocardial Infarction
Circulation, December 10, 2002; 106(24): 3126 - 3132.
[Abstract] [Full Text] [PDF]


Home page
Am. J. Physiol. Heart Circ. Physiol.Home page
P. C. Brum, J. Kosek, A. Patterson, D. Bernstein, and B. Kobilka
Abnormal cardiac function associated with sympathetic nervous system hyperactivity in mice
Am J Physiol Heart Circ Physiol, November 1, 2002; 283(5): H1838 - H1845.
[Abstract] [Full Text] [PDF]


Home page
Circ. Res.Home page
H. Funakoshi, T. Kubota, N. Kawamura, Y. Machida, A. M. Feldman, H. Tsutsui, H. Shimokawa, and A. Takeshita
Disruption of Inducible Nitric Oxide Synthase Improves {beta}-Adrenergic Inotropic Responsiveness but Not the Survival of Mice With Cytokine-Induced Cardiomyopathy
Circ. Res., May 17, 2002; 90(9): 959 - 965.
[Abstract] [Full Text] [PDF]


Home page
Am. J. Physiol. Heart Circ. Physiol.Home page
G. Wright, I. S. Singh, J. D. Hasday, I. K. Farrance, G. Hall, A. S. Cross, and T. B. Rogers
Endotoxin stress-response in cardiomyocytes: NF-kappa B activation and tumor necrosis factor-alpha expression
Am J Physiol Heart Circ Physiol, March 1, 2002; 282(3): H872 - H879.
[Abstract] [Full Text] [PDF]


Home page
Cardiovasc ResHome page
W. S. Bradham, B. Bozkurt, H. Gunasinghe, D. Mann, and F. G. Spinale
Tumor necrosis factor-alpha and myocardial remodeling in progression of heart failure: a current perspective
Cardiovasc Res, March 1, 2002; 53(4): 822 - 830.
[Abstract] [Full Text] [PDF]


Home page
HeartHome page
C G Densem, I V Hutchinson, N Yonan, and N H Brooks
Tumour necrosis factor {alpha} gene polymorphism: a predisposing factor to non-ischaemic myocardial dysfunction?
Heart, February 1, 2002; 87(2): 153 - 155.
[Abstract] [Full Text] [PDF]


Home page
Cardiovasc ResHome page
D. Hilfiker-Kleiner, A. Hilfiker, B. Schieffer, D. Engel, D. L Mann, K. C Wollert, and H. Drexler
TNF{alpha} decreases {alpha}MHC expression by a NO mediated pathway: role of E-box transcription factors for cardiomyocyte specific gene regulation
Cardiovasc Res, February 1, 2002; 53(2): 460 - 469.
[Abstract] [Full Text] [PDF]


Home page
Am. J. Physiol. Regul. Integr. Comp. Physiol.Home page
P. O. Iversen, P. R. Woldbaek, T. Tonnessen, and G. Christensen
Decreased hematopoiesis in bone marrow of mice with congestive heart failure
Am J Physiol Regulatory Integrative Comp Physiol, January 1, 2002; 282(1): R166 - R172.
[Abstract] [Full Text] [PDF]


Home page
Am. J. Physiol. Heart Circ. Physiol.Home page
P. O. Iversen, G. Nicolaysen, and M. Sioud
DNA enzyme targeting TNF-alpha mRNA improves hemodynamic performance in rats with postinfarction heart failure
Am J Physiol Heart Circ Physiol, November 1, 2001; 281(5): H2211 - H2217.
[Abstract] [Full Text] [PDF]


Home page
CirculationHome page
T. Kadokami, C. Frye, B. Lemster, C. L. Wagner, A. M. Feldman, and C. F. McTiernan
Anti-Tumor Necrosis Factor-{alpha} Antibody Limits Heart Failure in a Transgenic Model
Circulation, September 4, 2001; 104(10): 1094 - 1097.
[Abstract] [Full Text] [PDF]


Home page
Am. J. Physiol. Heart Circ. Physiol.Home page
T. Kadokami, C. F. McTiernan, T. Kubota, C. S. Frye, G. S. Bounoutas, P. D. Robbins, S. C. Watkins, and A. M. Feldman
Effects of soluble TNF receptor treatment on lipopolysaccharide-induced myocardial cytokine expression
Am J Physiol Heart Circ Physiol, May 1, 2001; 280(5): H2281 - H2291.
[Abstract] [Full Text] [PDF]


Home page
CirculationHome page
B. Bozkurt, G. Torre-Amione, M. S. Warren, J. Whitmore, O. Z. Soran, A. M. Feldman, and D. L. Mann
Results of Targeted Anti-Tumor Necrosis Factor Therapy With Etanercept (ENBREL) in Patients With Advanced Heart Failure
Circulation, February 27, 2001; 103(8): 1044 - 1047.
[Abstract] [Full Text] [PDF]


Home page
CirculationHome page
D. L. Mann
Tumor Necrosis Factor and Viral Myocarditis: The Fine Line Between Innate and Inappropriate Immune Responses in the Heart
Circulation, February 6, 2001; 103(5): 626 - 629.
[Full Text] [PDF]


Home page
Proc. Natl. Acad. Sci. USAHome page
Y. Y. Li, Y. Q. Feng, T. Kadokami, C. F. McTiernan, R. Draviam, S. C. Watkins, and A. M. Feldman
Myocardial extracellular matrix remodeling in transgenic mice overexpressing tumor necrosis factor alpha can be modulated by anti-tumor necrosis factor alpha therapy
PNAS, November 7, 2000; 97(23): 12746 - 12751.
[Abstract] [Full Text] [PDF]


Home page
Am. J. Physiol. Heart Circ. Physiol.Home page
H. Funakoshi, T. Kubota, Y. Machida, N. Kawamura, A. M. Feldman, H. Tsutsui, H. Shimokawa, and A. Takeshita
Involvement of inducible nitric oxide synthase in cardiac dysfunction with tumor necrosis factor-alpha
Am J Physiol Heart Circ Physiol, June 1, 2002; 282(6): H2159 - H2166.
[Abstract] [Full Text] [PDF]


This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrowRequest Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kubota, T.
Right arrow Articles by Feldman, A. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kubota, T.
Right arrow Articles by Feldman, A. M.
Right arrowPubmed/NCBI databases
*Substance via MeSH
Medline Plus Health Information
*Cardiomyopathy
Related Collections
Right arrow Growth factors/cytokines
Right arrow Heart failure - basic studies
Right arrow Gene therapy