SIRT3-AMPK Activation by Nitrite and Metformin Improves Hyperglycemia and Normalizes Pulmonary Hypertension Associated with Heart Failure with Preserved Ejection Fraction (PH-HFpEF)
Background—Pulmonary hypertension associated with heart failure with preserved ejection fraction (PH-HFpEF) is an increasingly recognized clinical complication of metabolic syndrome. No adequate animal model of PH-HFpEF is available and no effective therapies have been identified to date. A recent study suggested that dietary nitrate improves insulin resistance in eNOS null mice, and multiple studies have reported that both nitrate and its active metabolite, nitrite, have therapeutic activity in pre-clinical models of PH.
Methods and Results—In order to evaluate the efficacy and mechanism of nitrite in metabolic syndrome associated with PH-HFpEF, we developed a "two-hit" PH-HFpEF model in rats with multiple features of metabolic syndrome due to double leptin receptor defect (obese ZSF1) with the combined treatment of VEGF receptor blocker SU5416. Chronic oral nitrite treatment improved hyperglycemia in obese ZSF1 rats by a process that requires skeletal muscle SIRT3-AMPK-GLUT4 signaling. The glucose lowering effect of nitrite was abolished in SIRT3 deficient human skeletal muscle cells, as well as in SIRT3 knockout mice fed a high-fat diet. Skeletal muscle biopsies from humans with metabolic syndrome after 12 weeks of oral sodium nitrite and nitrate treatment (IND#115926) displayed increased activation of SIRT3 and AMPK. Finally, early treatments with nitrite and metformin at the time of SU5416 injection reduced pulmonary pressures and vascular remodeling in the PH-HFpEF model with robust activation of skeletal muscle SIRT3 and AMPK.
Conclusions—These studies validate a rodent model of metabolic syndrome and PH-HFpEF, suggesting a potential role of nitrite and metformin as a preventative treatment for this disease.
- Received August 10, 2015.
- Revision received December 1, 2015.
- Accepted January 8, 2016.