Introduction
Chronic heart failure (CHF) is a late-stage manifestation of various chronic cardio-cerebrovascular disorders [
1,
2]. With the increasing aging population and rising incidence of chronic diseases such as diabetes, dyslipidemia, hypertension, coronary atherosclerotic heart disease, and obesity, the prevalence of CHF continues to rise [
3,
4]. Although new medical technologies make it possible to extend the survival time of these patients, the majority of individuals eventually develop heart failure. CHF patients’ hearts exhibit aberrant changes in shape and function, often with ventricular systolic or diastolic dysfunction [
5]. According to a China heart failure prevalence analysis, the prevalence of heart failure in urban China is 275 per 100,000 person-years [
6]. The Chinese Heart Failure Registration Study reported that the mortality of patients with heart failure is 4.1% [
7]. While in-hospital mortality has decreased significantly, the rate of rehospitalization continues to rise and patients have a poor prognosis [
8]. Therefore, scientists aim to enhance patients’ quality of life, reduce mortality and rehospitalization rates, and improve long-term prognosis. To achieve these goals, more efficient prevention and treatment strategies are necessary.
Ventricular remodeling is considered the primary cause of CHF [
9], which can be triggered by various factors including cardiac hypertrophy, myocyte apoptosis and autophagy, collagen deposition in the extracellular matrix, fibrosis, changes in metabolic and electrophysiological characteristics, and inflammation [
10,
11]. Angiotensin-converting enzyme inhibitors, such as captopril, are a first-line therapy for patients with a reduced ejection fraction [
12], as they are known to reduce inflammation and apoptosis of myocardial cells [
13,
14]. Captopril has a dual effect of inhibiting and inducing cell apoptosis, while also reversing the inflammatory response mediated by autophagy according to fundamental investigations [
15]. Autophagy and apoptosis are two distinct mechanisms of programmed cell death that regulate the cell viability and death. While apoptosis can protect cells, tissues, and organs from necrosis-induced inflammatory responses, excessive apoptosis can lead to tissue damage [
16]. Autophagy, on the other hand, is the primary survival mechanism for cells in times of stress, allowing them to recycle cellular structures and create energy substances; however, excessive activation of autophagy can also cause damage to intracellular molecules and organelles, leading to organ injury [
17]. It is evident that both cell apoptosis and autophagy, which are related to inflammation, may be key mechanisms involved in myocardial injury.
Total glucosides of paeony (TGP) possess well-demonstrable antioxidant, anti-inflammatory, and immunomodulatory properties and have shown potential as a treatment for cardiovascular disease [
18]. Evidence suggests that TGP can effectively reduce inflammation and protect heart failure in rats suggesting its potential value for clinical applications [
19]. TGP has been used to treat rheumatoid arthritis as an anti-inflammatory immunomodulator agent. More recently, it has been found to inhibit myocardial inflammation, counteract arteriosclerosis, and enhance myocardial remodeling [
20]. Clinical investigations have demonstrated that TGP effectively suppresses inflammation in stable CHF patients by reducing the release of proinflammatory cytokines, including tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) [
20]. These cytokines play a critical role in the body’s inflammatory response. Research has linked poly(ADP-ribose) polymerase-1 (PARP-1), a key gene for many TCM [
21‐
23], and is involved in autophagy, to the expression of TNF-α and IL-6 [
24], as well as oxidative stress and autophagy in vascular smooth muscle cells [
25]. In animal models of CHF, inhibition of PARP leads to significant improvement in left ventricular systolic pressure, ventricular contractility, and relaxation [
26]. It also reduces nuclear translocation of nuclear factor kappa-B (NF-κB) protein, thereby decreasing the expression of inflammatory cytokines in cardiovascular and cerebrovascular diseases, through preventing [
27]. Therefore, PARP-1 is closely related to the anti-inflammation and autophagy in treatment effects of TGP in treating CHF. Although TGP has excellent potential as a clinical therapy for CHF, its unknown mechanism limits its wider use. This study aims to explore the role and mechanism of TGP in treating CHF using animal and cell models of the disease.
Methods and Materials
Animal Model
TGP capsules were manufactured by Ningbo Lihua Pharmaceutical Co., Ltd., of Zhejiang Province, China, approved by the China Food and Drug Administration (approval number: H20055058), and the main active ingredient is paeoniflorin. TGP was diluted into 10- and 5-g/L suspensions (1% CMC-Na) before use, while captopril (95% purity) was obtained from Shanghai Pukang Pharmaceutical Co., Ltd., China, and diluted to 2.25 g/L (distilled water) and stored at 4 °C for future use.
By ligating the left anterior descending artery (LAD) in 10-week-old male Wistar rats (Shanghai Laboratory Animal Center, Chinese Academy of Sciences), a heart failure model was established. The rats were given 80 mg/kg ketamine and 5 mg/kg acepromazine (both from Sigma-Aldrich, St. Louis, MO, USA), and a left thoracotomy was conducted. The heart was externalized, and a Prolene 6-0 suture was used to ligate the LAD 2 mm from its origin. Sutures were passed but not knotted in the sham-operated animals. The animals were then closed in three layers following the technique. To combat bacterial infection immediately following surgery, penicillin was administered intraperitoneally at a rate of 200,000 U/day for 3 days. In the next 4 weeks, the rats were separated into six groups (n = 9): control group (Ctrl), sham group, model group (CHF), CHF+captopril group [CHF+Cap; CHF rats were given Cap (15 mg/kg) by gavage, once a day for 12 weeks], CHF+TGP-low dosage group [CHF+TGPlow; CHF rats were given TGP (200 mg/kg) by gavage, once a day for 12 weeks], and CHF+TGP-high dose [CHF+Caphigh; CHF rats were given TGP (400 mg/kg) by gavage, once a day for 12 weeks]. The rats in the control, sham, and CHF groups received distilled water (0.2 mL/10 g) by gavage, once a day for 12 weeks.
Echocardiography for Cardiac Function Evaluation
After the end of the 24-h gavage, echocardiography was used for left ventricular (LV) cardiac structure and function in rats as previously reported [
28]. Rats were injected with anesthesia of 3% isoflurane (1% isoflurane for maintaining). The procedure was performed by an expert operator blinded to the treatment assignment using a 20-MHz probe connected to a Vevo 770 high-frequency ultrasound system, which was used to image the LV (VisualSonics, Toronto, ON, Canada). The main indicators for analysis are ejection fraction (EF) and fractional shortening (FS).
Blood Samples and Heart Tissues
Blood samples: After a 48-h echocardiography, animals were deprived of food and water for 3 h before weighting and blood collection. To induce anesthesia in the rats, 1% pentobarbital sodium was injected into the abdominal cavity. After immediately opening their abdominal aorta, 10–15 mL of arterial blood was taken using vacuum vasculature. The blood is allowed to stand until coagulation occurs to collect serum. Next, centrifugation was performed at 3000 rpm for 15 min at 4 °C, and the serum was transferred to 500-μL EP tubes and stored at −80 °C for future research.
Heart tissues: The auricular appendix was removed from the thoracic cavity of rats. The abdominal aorta was perfused with 0.9% saline solution (60–120 mL) until the liquid flowing out became clear in color. The rat heart was dissected and cleaned with normal saline before being dried on filter paper. The weight of the heart was determined using an electronic balance. Fresh heart tissue (taken from 3 rats per group) was fixed using 2.5% glutaraldehyde, while other hearts (taken from 3 rats per group) were rapidly frozen in liquid nitrogen and stored in freezing tubes at −80 °C. An additional set of hearts was preserved using 4% paraformaldehyde fixative for detecting gene and protein expression.
Observation of Cardiac Histopathology and Cell Apoptosis
Observation of pathological changes in myocardial tissue was done using hematoxylin-eosin (H&E) staining, myocardial fibrosis was observed using Masson’s trichrome staining, and cell apoptosis was measured using terminal dUTP nick end labeling (TUNEL) assay. The hearts of the rats in each group were extracted, fixed in 4% paraformaldehyde, embedded in paraffin, and sectioned into 5-μm sections. Following that, H&E staining kit (G1003, Servicebio, China), Masson’s trichrome staining kit (G1006, Servicebio, China), and TUNEL staining kit (G1507, Servicebio, China) were used for observing LV myocardial slices. According to H&E staining results, the degrees of tissue cell damage, fiber arrangement, and inflammatory cell infiltration were evaluated based on a previous report [
29]. For Masson’s trichrome staining, in an average of five sections from each heart, myocardial fibrosis was reported as a proportion of fibrotic area to left ventricular area (% of LV). Under light microscopy, the number of TUNEL-positive cardiomyocyte nuclei was manually counted in total, including the LV posterior wall and septum, from each LV short-axis segment. We counted and represented as a percentage of total cardiomyocytes in a specific LV region only the nuclei obviously found inside cardiomyocytes.
Transmission Electron Microscope for Tissues
Myocardial tissues were fixed with 2.5% glutaraldehyde (111-30-8, Alfa Aesar, UK) and were cut into 1 mm × 1 mm × 1 mm pieces. After cleaning, dehydrating, embedding, slicing, and staining the tissues, they were viewed using a transmission electron microscope (TEM) (H-7650, Hitachi, Tokyo, Japan). A pathologist conducted all exams at a magnification of ×30,000. Each tissue sample was examined for its myofibrillar structure, mitochondrial membrane, and characteristic autophagic vacuoles.
ELISA Assay
Following collection of a blood sample from rats, the concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) (MM-032R1), C-reactive protein (CRP) (MM-0081R1), TNF-α (MM-0180R1), IL-6 (MM-0190R1), and monocyte chemotactic protein-1 (MCP-1) (MM-0099R1) in the serum were determined using an enzyme-linked immunosorbent assay (ELISA) (MEIMIAN, China) according to the manufacturer’s instructions. The values were standardized to the quantities of cell protein in the samples.
Cell Culture
The H9C2 rat cardiomyocytes were obtained from the Cell Bank of the Chinese Academy of Sciences (Shanghai, China) and cultured in Dulbecco’s modified Eagle’s medium (DMEM) (11885084, Gibco, USA) supplemented with 10% fetal bovine serum (FBS) (10099141C, Gibco, USA) and 100 U/mL penicillin/100 mg/mL streptomycin at 37 °C in an atmosphere of 90% air and 10% CO2; the medium was replenished every 2 days; and the cells were digested with 0.05% trypsin when the density of the cells reached 80–90%. H9C2 cells (1 × 105 cells/mL) were seeded in a 25-cm2 culture flask (430639) or 6-well (3506) or 96-well culture plates (353936) and treated identically to those used in the subsequent investigations. They were purchased from Corning Incorporated, NY, USA.
Transfection
H9C2 cells (1 × 105 cells/mL) were transfected with poly(ADP-ribose)polymerase 1 (PARP-1) siRNA (sc-29437, Santa Cruz Biotechnology, CA, USA) or a negative control in Opti-MEM Medium (31985062, Invitrogen, USA) in order to decrease PARP-1 expression. H9C2 cells were transfected with the plasmids pcDNA3.1-PARP-1 or pcDNA3.1-vector (GeneChem Co., Ltd., Shanghai, China) in serum-free media. Lipofectamine 2000 (11668019, Invitrogen, USA) was used to transfection. The experiments were carried out 48 h following the transfection.
Cell Treatment
Adriamycin (ADR) treatment induces myocardial cell damage leading to heart failure [
30]. Therefore, we used ADR-incubated cells to induce myocardial cell injury and observed the protective effect of TGP on myocardial cells. Four major experimental groups were established in the current investigation: (i) control group: DMEM, (ii) ADR group: adriamycin treatment (2 μM) for 48 h, (iii) ADR+TGP group: TGP treatment (10 μg/mL) for 12 h followed by ADR treatment (2 μM) for 48 h, (iv) ADR+TGP+OE-PARP-1 group: TGP treatment (10 μg/mL) for 12 h followed by ADR treatment (2 μM) of pcDNA3.1-PARP-1 transfected H9C2 cell for 48 h.
Western Blot
Total protein from the treated cells and tissues was extracted using RIPA buffer containing 1 mmol/L PMSF (P0013D, Beyotime, China) and quantified using the BCA Protein Assay Kit (pc0020, Solarbio, China). SDS-PAGE was used to separate the protein bands, which were then transferred to a polyvinylidene difluoride (PVDF) membrane for analysis (10600023, GE Healthcare Life, USA). After being blocked with 5% bovine serum albumin (4240GR100, BioFroxx, Germany) in phosphate-buffered saline with Tween (PBST) for 1 h, the PVDF membrane was incubated with primary antibodies including cleaved caspase-3 (AF7022, Affinity, USA), TNF-α (AF7014, Affinity, USA), IL-6 (DF6087, Affinity, USA), NF-κB (AF5006, Affinity, USA), PARP-1 (ab32064, Abcam, UK), and GAPDH (AF7021, Affinity, USA) overnight at 4 °C and then with the secondary antibody for 1 h at room temperature before being exposed to the secondary antibody. The signals were determined by the Amersham Prime ECL Plus Detection system (Pittsburgh, PA).
Flow Cytometry Analysis
Flow cytometry was used to identify apoptosis. To summarize, after collecting the cells processed according to grouping requirements using EDTA-free trypsin (BL526A, Biosharp, China), they were washed twice with PBS and filtered through a 300-mesh nylon to get a single-cell suspension. The cell density is 2 × 105 cells/mL. Then, the Annexin V-FITC apoptosis detection kit (APOAF-20TST, Sigma, Japan) was used to determine the apoptosis rates. Annexin V-FITC (5 μL) was added into a 195-μL cell suspension to incubate for 10 min at 25 °C. Cells were washed and resuspended in 190 μL binding buffer (1×). After adding 10 μL propidium iodide, samples were performed to flow cytometry (Accuri C6, BD, NJ, USA).
CCK-8 Assay
Cell viability was determined according to the manufacturer’s procedure using Cell Counting Kit-8 (CCK-8, Beyotime, Shanghai, China). Cells were seeded and cultured at a density of 5 × 103/well in 100 μL of medium in 96-well microplates (Corning, USA). Cells were incubated sequentially in complete medium containing ADR, TGP, or no treatment according to their designated groupings. After treatment for 72 h, 10 μL of CCK-8 was added to each well and then cultured for 2 h. All experiments were performed in triplicate. The absorbance at 450 nm was determined using a microplate reader (Bio-Rad, Hercules, CA, USA) with blank wells. The absorbance of cells was used to quantify their proliferation.
Real-Time Polymerase Chain Reaction (RT-PCR)
The TRIzol extraction method was used to extract RNA from cells and tissues (Invitrogen, CA, USA). Following that, cDNA was evaluated by RT-PCR using iQ™ SYBR Green Supermix (Bio-Rad Laboratories, CA, USA). The sequences of specific primers are as follows: PARP-1-F: ACCACGCACAATGCCTATGA, PARP-1-R: AGCAGTCTCCGGTTGTGAAG; GAPDH-F: TTCCTACCCCCAATGTATCCG, GAPDH-R: CATGAGGTCCACCACCCTGTT. The real-time PCR system was used for amplification, detection, and data processing (Bio-Rad Laboratories). The real-time program featured a 1.5-min denaturation phase at 95 °C, 40 cycles at 95 °C for 15 s, and 30 s at 60 °C. Each sample was analyzed in triplicate, and each experiment was performed three times. The 2−ΔΔCt method was used to analyze the relative changes in gene expression.
Immunofluorescence
H9C2 cells were pretreated for 30 min with PBS or remifentanil and then treated differently. Following that, the cells were fixed in 4% paraformaldehyde and permeabilized in PBS containing 0.1% Triton X-100. After 30 min of blocking with BSA, the samples were incubated overnight at 4 °C with primary antibody rabbit anti-NF-κB p65 (1: 100, #8242, Cell Signaling Technology, USA). As a secondary antibody, Alexa 488-conjugated goat anti-rabbit IgG (1: 500, #4414S, Cell Signaling Technology, USA) was utilized. To seal the coverslip, a drop of ProLong Gold Antifade Reagent containing 4′,6-diamidino-2-phenylindole (DAPI; Vector Laboratories, CA, USA) was utilized. Laser scanning confocal microscopy was used to obtain the images (LSM 710, Zeiss, Germany). Image-Pro Plus 6.0 was used to examine the data.
Transmission Electron Microscopy for Cellular Ultrastructure Analysis
As previously reported [
31], we used electron microscopy to observe the cellular ultrastructure. Briefly, the cell culture medium was replaced with 2.5% glutaraldehyde anterior fixative to fix for 2 h at 25 °C and then 1% osmic acid was used to further fix for 2 h at 4 °C. After sequential dehydration, washing, and embedding, the cell samples were cut into ultrathin slices (100 nm) using an ultramicrotome and counterstained with 0.3% uranium acetate and lead nitrate, and the number of autophagosomes was evaluated using a TEM (H-7650, Hitachi, Tokyo, Japan).
Statistical Analysis
All data were analyzed using SPSS 25 (IBM, USA) and presented as mean ± standard deviation (SD). GraphPad Prism 9 (GraphPad Software, USA) was used to display the results. Multi-group comparisons were performed by one-way analysis of variance (ANOVA) followed by Tukey post-hoc test for homogenous variance or Dunnett’s T3 for non-homogenous variance. Additionally, Kruskal-Wallis test was used for analyzing data that did not follow a normal distribution. P < 0.05 was considered as statistically significant.
Discussion
Our main findings indicate that treatment with TGP improved heart function in CHF rats. Additionally, TGP inhibited both autophagy and apoptosis of cardiomyocytes as well as PARP-1 and the NF-κB pathway to prevent the progression of CHF. Several factors contribute to cardiac remodeling and exacerbate CHF, such as myocardial hypertrophy and fibrosis, aberrant myocardial cell apoptosis and autophagy, and inflammatory response [
34,
35]. We simulated CHF in rats by performing LAD ligation, which is a common procedure for simulating CHF [
36]. Additionally, to determine the ventricular failure status of rats, we measured their NT-pro-BNP levels (a clinical biomarker for heart failure diagnosis [
37]), inflammatory factors, cardiac impulse, atrioventricular diameter, and hemodynamics. Inflammatory factors tend to be elevated in CHF patients compared to healthy individuals; increased levels of inflammatory markers (CRP, TNF-α, IL-6, MCP-1) and NT-pro BNP have been found to correlate with the CHF severity [
38,
39]. Consistent with clinical results, our results showed that LAD ligation induced heart failure, characterized by reduced FS, EF, and cardiac chamber expansion.
To evaluate TGP’s therapeutic efficacy in treating CHF rats, we used captopril-treated CHF rats as a positive control group. Our study revealed that a high dose of TGP effectively improved myocardial damage, delayed ventricular remodeling, controlled inflammatory responses, and reduced myocardial fibrosis. The effects of TGP in CHF rats were comparable to those of captopril-treated CHF rats. However, unlike captopril, TGP prevented autophagy. Captopril has been shown to suppress autophagy at doses more than 50 mg/kg [
40,
41], but in this study, we used a low-dose captopril (15 mg/kg) that may induce protective autophagy. Autophagy protects cells from external stimuli and helps them escape apoptosis triggered by pathogenic damage or stress [
42]. Autophagy is tightly linked to cardiomyocyte self-metabolism and is involved in ventricular remodeling [
43]. Excessive autophagy can also induce myocardial apoptosis and fibrosis, leading to left ventricular dysfunction [
44]. Our study indicates that TGP may inhibit excessive autophagy in the myocardium of CHF rats, which may be one of the molecular processes behind TGP’s effectiveness in treating heart failure.
We observed a significant overexpression of PARP-1 and NF-κB in the myocardial tissue of CHF rats. PARP-1 plays a crucial role in the progression of various cardiovascular diseases [
45,
46]. Its activation exacerbates myocardial ischemia-reperfusion damage by promoting autophagy [
23]. Moreover, the increased expression of PARP-1 may boost the expression and nuclear translocation of NF-κB p65, leading to elevated levels of TNF-α and IL-6, thereby initiating an inflammatory response [
47]. In addition, activation of NF-κB enhances cell autophagy and the inflammatory response increasing cell apoptosis [
48]. Our results indicate that PARP-1 represents a viable therapeutic target in the treatment of CHF. Interestingly, we found that low-dose captopril can increase PARP-1 and NF-κB expression and might increase protective autophagy through increased PARP-1 expression. We speculate that increased PARP-1 expression may enhance the release of inflammatory substances by increasing NF-κB expression, which may be the primary cause for low-dose captopril treatment on CHF without inhibiting TNF-α. Our study revealed that PARP-1 overexpression promoted the nuclear translocation of NF-κB and increased the expression of LC3, TNF-α, and IL-6. Conversely, TGP decreased the expression of PARP-1 and NF-κB, indicating that the anti-heart failure action of TGP is mediated by modulation of the PARP-1 and the NF-κB signaling pathway. Overexpression of PARP-1 antagonized TGP’s protective effect. To summarize, TGP suppressed cell apoptosis, autophagy, and inflammatory response induced by CHF via inhibiting the PARP-1 and the NF-κB signaling pathway.
However, there are limitations to this study, particularly regarding the use of TGP as a mixture containing paeoniflorin. Further investigation is necessary to compare the effectiveness of the paeoniflorin, etc., components and TGP for myocardial protection. Additionally, determining the effective dose threshold for clinical application requires further research into dose groups and TGP toxicology. In order to enhance understanding of TGP’s therapeutic capacity for cardiac failure, it would also be beneficial to utilize a larger number and greater variety of cardiac failure models. In conclusion, the data imply that autophagy activation may contribute to ventricular remodeling in patients with CHF. Treatment with TGP might serve a heart-protective role in CHF, presumably via suppressing the autophagy process. Further study is needed to elucidate the involvement of autophagy and the PARP-1/NF-κB signaling pathway in the TGP treatment for CHF. This investigation may result in the development of innovative treatment options for people with congestive heart failure.
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