Pharmacology & Therapeutics 122 (2009) 246263

Contents lists available at ScienceDirect

Pharmacology & Therapeutics

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p h a r m t h e r a

Associate editor: B.J. McDermott

Signicance of peroxisome proliferator-activated receptors in the cardiovascular system in health and disease
Emma Robinson, David J. Grieve
Centre for Vision and Vascular Science, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 3rd Floor, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL UK

a r t i c l e

i n f o

a b s t r a c t
Peroxisome proliferator-activated receptors (PPARs) are ligand-activated nuclear transcription factors that belong to the nuclear receptor superfamily. Three isoforms of PPAR have been identied, , and , which play distinct roles in the regulation of key metabolic processes, such as glucose and lipid redistribution. PPAR is expressed predominantly in the liver, kidney and heart, and is primarily involved in fatty acid oxidation. PPAR is mainly associated with adipose tissue, where it controls adipocyte differentiation and insulin sensitivity. PPAR is abundantly and ubiquitously expressed, but as yet its function has not been clearly dened. Activators of PPAR (brates) and (thiazolidinediones) have been used clinically for a number of years in the treatment of hyperlipidaemia and to improve insulin sensitivity in diabetes. More recently, PPAR activation has been found to confer additional benets on endothelial function, inammation and thrombosis, suggesting that PPAR agonists may be good candidates for the treatment of cardiovascular disease. In this regard, it has been demonstrated that PPAR activators are capable of reducing blood pressure and attenuating the development of atherosclerosis and cardiac hypertrophy. This review will provide a detailed discussion of the current understanding of basic PPAR physiology, with particular reference to the cardiovascular system. It will also examine the evidence supporting the involvement of the different PPAR isoforms in cardiovascular disease and discuss the current and potential future clinical applications of PPAR activators. 2009 Elsevier Inc. All rights reserved.

Keywords: Peroxisome proliferator-activated receptor (PPAR) Cardiovascular disease (CVD) Heart Atherosclerosis Hypertension Hypertrophy

Contents 1. Introduction . . . . . . . . . . . . 2. PPARs and the cardiovascular system 3. Conclusions . . . . . . . . . . . . Acknowledgment . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 250 253 258 254 258 254 258

Abbreviations: ACE, Angiotensin-converting enzyme; AF, Activation function; ANF, Atrial natriuretic factor; Ang II, Angiotensin; AP-1, Activator protein-1; BNP, Brain natriuretic peptide; COX, Cyclooxygenase; CVD, Cardiovascular disease; DBD, DNA binding domain; DHA, Docosahexaenoic acid; DOCA, Deoxycorticosterone acetate; ERK, Extracellular regulated kinase; ET, Endothelin; FATP, Fatty acid transport protein; HDL, High density lipoprotein; ICAM, Intercellular adhesion molecule; IL, Interleukin; LBD, Ligand binding domain; LDL, Low density lipoprotein; L-NAME, N-nitro-L-arginine methyl ester; LV, Left ventricular; MAPK, Mitogen activated protein kinase; MCP-1, Monocytic chemotactic protein-1; MI, Myocardial infarction; MMP, Matrix metalloproteinases; NADPH, Nicotinamide adenosine dinucleotide phosphate; NcoR, Nuclear receptor co-repressor; NF-B, Nuclear factor-kappa B; NO, Nitric oxide; NOS, Nitric oxide synthase; PGC-1, Peroxisome proliferator-activated receptor gamma co-activator-1; PPAR, Peroxisome proliferatoractivated receptor; PPRE, Peroxisome proliferator response element; ROS, Reactive oxygen species; RXR, Retinoid X receptor; SHR, Spontaneously hypertensive rats; SMRT, Silencing mediator for retinoid and thyroid hormone receptor; STAT, Signal transducers and activator of transcription; TNF, Tumour necrosis factor ; VCAM, Vascular cell adhesion molecule. Corresponding author. Tel.: +44 2890972097; fax: +44 2890975775. E-mail address: d.grieve@qub.ac.uk (D.J. Grieve). 0163-7258/$ see front matter 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.pharmthera.2009.03.003

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263

247

1. Introduction Despite major therapeutic advances, cardiovascular disease (CVD) remains one of the leading causes of morbidity and mortality in the western world. Traditional risk factors for CVD include hypertension, hyperglycaemia and dyslipidaemia (Kannel, 1997). However the rapidly increasing incidence of metabolic disorders such as diabetes, obesity and metabolic syndrome combined with more aggressive treatment of hypertension is shifting the underlying aetiology towards hyperglycaemia and dyslipidaemia. CVD is frequently characterised by dysregulation of fatty acids, particularly in patients with metabolic disease (Abate, 2000; Grundy, 2004). In healthy individuals the rates of uptake and utilisation of fatty acids are tightly controlled in order to match tissue energy demands and maintain lipid balance. However, when this balance is upset the subsequent increase in circulating fatty acids becomes a primary risk factor for the development of hypertension and atherosclerosis (Egan et al., 2001). Several classes of drugs, including bile acid sequestrants, brates and statins, have been used historically to reduce cholesterol levels and maintain physiological plasma concentrations (Knopp, 1999). Of these, statins have now become the primary therapeutic choice for CVD prevention, subsequent to several large-scale primary and secondary clinical trials which demonstrated that chronic treatment caused a signicant reduction in the incidence of coronary heart disease (Scandinavian Study Simvastatin Survival Group Study 1994; Shepherd et al., 1995). Nevertheless, there remains a substantial incidence of CVD in optimally-treated patients, especially those with additional underlying pathologies, such as diabetes. In the ongoing search for a more effective alternative to statins, recent attention has begun to focus on brates and thiazoldidenodiones, due to their therapeutic value in the specic treatment of hyperlipidaemia and diabetes, respectively. These drugs exert their effects via activation of peroxisome proliferator-activated receptors (PPARs), which belong to the nuclear hormone receptor superfamily. This review will discuss the current understanding of PPAR physiology and pharmacology and how activation of the PPAR pathway may modify the development of several diseases of the cardiovascular system. 1.1. PPAR discovery and classication Peroxisomes are subcellular organelles whose classical role is to remove hydrogen through the use of molecular oxygen via a series of oxidase and catalase enzymes. They also play a crucial role in several cellular metabolic processes, including the catabolism of cholesterol to bile and the -oxidation of fatty acids. Under normal physiological conditions, peroxisome metabolism occurs secondary to that in the mitochondrial system (Vamecq & Drey, 1989), and primarily involves oxidation of very long-chain fatty acids that cannot be otherwise metabolised. In rat liver cells activation of peroxisomes by various pharmacological stimuli has been shown to induce peroxisomes to increase in size and number (Reddy & Krishnakantha, 1975; Lock et al., 1989), and is associated with an increased expression of genes involved in fatty acid oxidation. In humans, pharmacological agents may activate peroxisomal gene transcription in a similar manner but in contrast to the rat there is no corresponding increase in

peroxisome size or number (Kliewer et al., 2001). The group of structurally disparate compounds, which were initially found to stimulate peroxisome proliferation in rats, were assigned as peroxisome proliferators although the mechanism of action of these compounds was unknown at that time. In 1990, the cloning of a mouse gene linked to peroxisome proliferation was rst described (Isseman & Green 1990). It was subsequently discovered that peroxisome proliferators acted via stimulation of an orphan nuclear hormone receptor, which was named the peroxisome proliferator-activated receptor or PPAR; the original receptor is now known as PPAR. Together, PPARs form group C in subfamily 1 of the superfamily of nuclear hormone receptors, i.e., NR1C. The large nuclear receptor superfamily comprises ligand-activated transcriptional factors that regulate the expression of a large number of genes involved in carbohydrate and lipid metabolism (Giguere, 1999). Also included in this group are the steroid, thyroid, vitamin D and retinoic acid receptors, as well as several other orphan receptors for which a ligand/activator has yet to be identied (Manglesdorf et al., 1995; Blumberg & Evans 1998). Leading on from the discovery of the prototypic mouse PPAR, (PPAR, NR1C1), the cDNA of two other major isotypes of this nuclear receptor subfamily, PPAR (NR1C2) and PPAR (NR1C3), were identied, although neither of these PPAR subtypes were found to be associated with peroxisome proliferation. All three PPARs are encoded by separate genes and have been found to be expressed in amphibians (Dreyer et al., 1992), rodents (Gottlichter et al., 1992; Kliewer et al., 1994) and humans (Schmidt et al., 1992; Sher et al., 1993; Greene et al., 1995). PPAR and PPAR appear to be highly conserved across species, whereas PPAR is considerably divergent (Kliewer et al., 1994). 1.2. PPAR structure and mechanism of action PPARs are compact ligand-activated transcription factors that control gene expression and have a structural organisation comparable to the other members of the nuclear hormone receptor family. PPARs have ve or six structural regions within four functional domains, known as A/B, C, D and E/F, as depicted in Fig. 1. The aminoterminal A/B domain, which is poorly conserved between the three PPAR isotypes, contains a ligand-independent activation function-1 (AF-1) (Werman et al., 1997). Phosphorylation in this region modulates receptor activity in an isotype-dependent manner; for example, insulin can stimulate PPAR-mediated transcription via mitogenactivated protein kinase (MAPK)-induced phosphorylation at Ser12 and Ser21 (Shalev et al., 1996; Juge-Aubry et al., 1999), whereas MAPKmediated phosphorylation of Ser112 has an inhibitory action on PPAR (Adams et al., 1997; Camp & Tafuri, 1997). The 70 amino acid long DNA binding domain (DBD) or C domain is comprised of two highly conserved zinc nger-like structures and promotes binding of the receptor to a DNA sequence in the promoter region of target genes, known as the peroxisome proliferator response element (PPRE) (Kliewer et al., 1992). The C-terminal, E/F domain or ligand binding domain (LBD) is responsible for ligand specicity and activation of PPAR binding to the PPRE of target genes. The D domain or hinge domain links the DBD to the LBD and acts as a docking site for co-factors. The N terminal or E/F domain recruits co-factors to assist the transcription

Fig. 1. Schematic Structure of PPAR. PPARs have six structural regions and four functional domains A/B, C, D and E/F. The amino-terminal A/B domain contains a ligand-independent activation function (AF-1). The C domain promotes PPAR binding to a DNA sequence. The C-terminal, E/F domain or ligand binding domain is responsible for ligand specicity of the receptor. The D domain or hinge domain links the DNA binding domain to the ligand binding domain and acts as a docking site for co-factors. The E/F domain also recruits co-factors to assist the transcription process via the ligand-dependent transactivation function (AF-2).

248

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263

initiates a sequence of events which ultimately lead to gene transcription (Soutoglou et al., 2001). Although co-activators and corepressors appear to be the major factors responsible for regulation of PPAR activity, these receptors can also be modulated by MAPK-induced phosphorylation, adding a further dimension to an already intricate system of control. For example, phosphorylation by extracellular regulated kinases (ERK) has been found to repress PPAR activity (Barger & Kelly, 2000), whereas that induced by p38 MAPK activation enhances PPAR-mediated gene expression (Barger et al., 2001). 1.4. PPAR ligands PPARs have a remarkable ability to be activated by a wide range of structurally diverse endogenous and synthetic ligands. However, heterogeneity of the LBD between the three PPAR isotypes is such that there is a degree of ligand specicity. Among the synthetic ligands, brates (e.g. Wy 14,643, clobrate, gembrozil, fenobrate, bezabrate) are a class of hypolipidemic drugs which are commonly used to reduce plasma triglycerides, an established risk factor for the development of CVD. Although the majority of brates preferentially activate PPAR, few are specic. Wy 14,643 and clobrate were the rst reported activators of PPARs; they are selective for PPAR at concentrations up to 10 M, but at higher concentrations also activate PPAR (Lehmann et al., 1997). Other PPAR agonists appear to have a higher afnity for PPAR, such as GW2331, which has a Kd of 140 nM (Kliewer et al., 1997). Glitazones are thiazolidinedione-based antidiabetic compounds which are preferential agonists of PPAR. Ciglitazone was originally derived from clobrate by optimisation of its weak glucose-lowering properties. In addition to these anti-hyperglycaemic actions, ciglitazone was also found to reduce glucose levels whilst retaining some of the lipid-lowering properties of brates. Since their initial discovery, more potent derivatives have been developed, such as rosiglitazone, pioglitazone and troglitazone (Kliewer et al., 2001). In general, PPAR agonists show greater selectivity than those of PPAR; for example, rosiglitazone, the rst high afnity PPAR ligand to be identied, has a Kd of 43 nM as compared to the micromolar afnities commonly associated with brates. In addition to agonists of PPAR and PPAR which have wide clinical applications, synthetic ligands for PPAR have also been developed (Berger et al., 1999). L165041, a phenoxyacetic acid derivative and GW0742X (Michalik et al., 2006) act as specic PPAR agonists, which may have benecial effects on lipid and glucose metabolism, in addition to playing a role in fertility and cancer. Despite concerted efforts to develop high afnity, isotypespecic PPAR agonists, it is becoming increasingly apparent that many synthetic PPAR ligands also exert PPAR-independent effects. Whilst much of the PPAR research to date employing such synthetic agonists has provided tremendous insight into PPAR biology, the results of these studies must be interpreted with care. It is clear that the existence of a specic endogenous ligand would enable a more focussed interrogation and detailed understanding of PPAR function, and considerable effort has been invested in this direction. The main candidate for an endogenous PPAR activator appears to be fatty acids, which are known to possess similar characteristics to brates; however, whether or not they are true natural PPAR ligands is still open to debate. An early investigation revealed that PPAR is activated by long-chain fatty acids (Gottlicher et al., 1992), and subsequently the ability of individual fatty acids of variable chain length and degree of saturation to act as ligands for the three PPAR isotypes has become the focus of many in vitro studies. PPAR subtypes have varying afnities for different fatty acids. For example, PPAR and PPAR have comparable afnities for long-chain saturated, monoand poly-unsaturated fatty acids, whereas PPAR has a very low afnity for saturated fatty acids (Forman et al., 1997; Johnson et al., 1997; Kliewer et al., 1997; Xu et al., 1999). However, the in vitro afnities of the these fatty acids for their respective PPARs are in the

Fig. 2. Basic mechanism of action of PPARs. PPARs bind to a specic sequence in the promoter of target genes (peroxisome proliferator response element; PPRE) and activate transcription. The PPAR/retinoid X receptor (RXR) heterodimer binds to the PPRE with PPAR occupying the 5half site whilst RXR occupies the 3 half site. The PPRE consensus sequence, 5-AGGTCA n AGGTCA-3, ts a DR1 pattern of two direct repeats spaced by one nucleotide, and is specic for the PPAR/RXR heterodimer, setting it apart from other nuclear receptors.

process via the ligand-dependent transactivation function (AF-2) (Berger & Moller, 2002). Upon activation by endogenous or synthetic ligands, PPARs, like other nuclear hormone receptors, form obligate heterodimers with the 9-cis retinoic acid receptors (retinoid X receptor, RXR), a process facilitated by the LBD. The resulting complex undergoes a conformational change which allows binding of the heterodimer to the PPRE (consensus sequence: 5-AGGTCA n AGGTCA-3), which is located in the promoter region of the target gene (Torra et al., 2001). The PPAR/ RXR heterodimer binds to the PPRE with PPAR occupying the 5 half site, whilst RXR occupies the 3 half site. The PPRE consensus sequence (5-AGGTCA n AGGTCA-3) ts a pattern of two direct repeats spaced by one nucleotide (DR1), and is specic for the PPAR/RXR heterodimer, setting it apart from other nuclear receptors, such as the thyroid or vitamin D receptors (Ijpenberg et al., 1997; Kliewer et al., 2001). Binding of the heterodimer complex to the PPRE is diagrammatically represented in Fig. 2. Ligands of either of the heterodimeric receptors are able to independently induce transcription of target genes, but when both PPAR and RXR are activated simultaneously, it results in signicant synergistic enhancement of gene transcription (Kleiwer et al., 1992; Mangelsdorf & Evans, 1995). 1.3. Co-activators/repressors of PPARs Many proteins act as co-activators or co-repressors that regulate the ability of nuclear hormone receptors, such as PPARs, to either stimulate or repress gene transcription. PPARs do not appear to be active under basal conditions. In the unbound state, PPAR/RXR heterodimers are associated with co-repressors, such as silencing mediator for retinoid and thyroid hormone receptor (SMRT) and nuclear receptor co-repressor (NcoR), which prevent gene transcription through their histone deacetylase activity (Chen & Evans, 1995; Horlein et al., 1995; Xu et al., 1999). However, once a ligand binds to the receptor a conformational change occurs that not only facilitates corepressor dissociation, but also the recruitment of several positive coactivators, including PBP, PPAR binding protein and steroid receptor co-activator 1 (SRC-1) (Zhu et al., 1997; Nolte et al., 1998). More recently identied co-activators include the PPAR co-activator-1 (PGC-1) proteins, PGC-1 (Puigserver et al., 1998) and PGC-1 (Lin et al., 2002), both of which are found in tissues which exhibit a high rate of mitochondrial metabolism. Once a ligand becomes bound to the receptor, the histone acetylase activity intrinsic to these co-activators

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263

249

micromolar to submillimolar range; if they were to be true selective endogenous ligands these afnities should be at much lower concentrations, within the nanomolar range. Another factor in consideration of fatty acids as potential endogenous PPAR ligands is the mechanism by which these labile molecules could become sufciently concentrated within the nucleus so as to activate PPAR. In this regard, it has recently been shown that both local generation within the nucleus via the action of phospholipases and fatty acid transport may be involved in fatty acid-mediated PPAR activation (Han et al., 2002; Tan et al., 2002; Gilde & Van Bilsen, 2003). Certain derivatives of fatty acids are also capable of binding to PPARs, with products of lipooxygenase and cyclooxygenase metabolism appearing to be more specic and potent than their fatty acid precursors. Indeed, a metabolite of the prostaglandin J2 group, 15d-PGJ2 and prostacyclin have previously been suggested to be natural ligands for PPAR and PPAR, respectively, due to their high afnities for each receptor (Forman et al., 1995; Kliewer et al., 1995; Lim et al., 1999). Despite this, recent evidence has demonstrated that 15d-PGJ2 exerts PPARindependent effects (Kaplan et al., 2007) which imply that it is not an endogenous PPAR ligand. Details of the endogenous and synthetic agonists of PPARs and their typical EC50 values are given in Fig. 3. 1.5. Selective PPAR modulators (SPPARM) Upon binding to PPARs, different ligands can induce different stimulatory or inhibitory responses depending on the nature of the specic target gene and its cellular location, a principle which has been termed the selective PPAR modulator (SPPARM) theory. It suggests that once ligands become bound to the receptor, they can each induce unique and distinct conformational changes, leading to differential co-activator/co-repressor interactions, enabling subtle differences in transcriptional activation of target genes. Therefore, distinct ligands for one common receptor are capable of inducing

different physiological responses depending on, for example, cell type. The SPPARM theory is currently being employed to aid the development of new generation PPAR agonists, with the hope that specic compounds may be identied that are capable of activating the transcription of desirable target genes whilst minimising/repressing the transcription of those which are detrimental (Chinetti-Gbaguidi et al., 2005a; Fruchart, 2007). 1.6. Tissue distribution of PPARs In order to begin to understand the complex physiological role of the different PPARs, it is essential to examine their tissue expression. In both rodents and humans, PPAR is predominantly expressed in cells with high rates of fatty acid catabolism and peroxisomedependent oxidation, such as those found in liver, heart, kidney, skeletal muscle, pancreas and intestinal mucosa (Braissant et al., 1996; Schoonjans et al., 1996a). PPAR is mainly associated with adipose tissue, with a low level of more ubiquitous expression in liver, heart, skeletal muscle and bone marrow (Escher & Wahli, 2000). Interestingly, splice variants of the human PPAR (PPAR1 and PPAR2) and more recently, PPAR have been identied (Fajas et al., 1997; Gervois et al., 1999). PPAR2 has been found to be exclusively and abundantly expressed in fat tissue, whereas PPAR1 has a more ubiquitous expression prole (Schoonjans et al., 1996b). PPAR is abundantly and ubiquitously expressed at much higher levels than PPAR and PPAR (Kliewer et al., 1994). It is important to note that tissue expression of all three PPAR isotypes is likely to vary under differing physiological and/or pathological conditions. 1.7. Physiological function of PPARs Activation of PPARs is a multifaceted process that relies on efcient receptor dimerisation, co-factor recruitment, phosphorylation and

Fig. 3. Table of typical EC50 values for endogenous and synthetic PPAR ligands at murine PPAR receptors. Synthetic PPAR agonists include the brates, which preferentially activate PPAR, and the glitazones, a thiazolidinedione-based group of anti-diabetic compounds which are preferential agonists of PPAR. Endogenous PPAR activators are predominantly fatty acids or their derivatives.

250

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263

ligand binding. The diverse physiological responses elicited by PPAR activation are made possible by the complexities of the receptor activation pathway and the disparate tissue expression of each receptor subtype. 1.7.1. PPAR Identication of PPAR target genes rst illustrated that PPAR is a major regulator of fatty acid homeostasis. PPAR controls the expression of a wide range of proteins involved in both the transport and -oxidation of free fatty acids. Specically, PPAR plays a critical role in the regulation of fatty acid transport protein (FATP), which facilitates the uptake of long-chain fatty acids across the plasma membrane, and several key enzymes involved in their subsequent catabolism within the cell. PPAR has been shown to induce activation of acyl-CoA oxidase, thiolase, acyl-CoA dehydrogenase and cytochrome P450 -hydroxylase, which are all essential to the -oxidation of fatty acids within peroxisomes, mitochondria and microsomes (Schoonjans et al., 1996b). It has been suggested that PPAR may also act as a cellular sensor capable of detecting changes in circulating free fatty acids or their associated metabolites and intermediates. PPAR-stimulated expression of lipoprotein lipase is known to promote the release of fatty acids from lipoprotein particles and their subsequent uptake (Schoonjans et al., 1996b). PPAR expression has also been found to be signicantly increased in situations of metabolic stress, such as fasting or severe cold, when increased energy production requires the release of fatty acids from adipose tissue (Lemberger et al., 1996). Denitive evidence to support the critical requirement of PPAR for effective lipid handling comes from a study in PPAR null mice which examined the effect of pharmacologic inhibition (etomoxir) of mitochondrial fatty acid import on lipid metabolism. Whereas wild-type animals were able to tolerate etomoxir treatment, PPAR null mice exhibited preferential lipid accumulation in tissues with a high rate of lipid oxidation, such as liver, heart and kidney, which may ultimately lead to lipotoxicity and death (Djouadi et al., 1998). Indeed, PPAR agonists are widely used in the treatment of disorders characterised by elevated levels of plasma lipids, i.e. dyslipidaemias. Fibrates exert their positive effects on lipid handling by inducing hepatic uptake and -oxidation of fatty acids and increasing lipoprotein lysis, whilst also conferring benecial effects on the high density lipoprotein (HDL) to low density lipoprotein (LDL) ratio. PPAR activation has also been shown to have anti-inammatory effects. In gene-modied mice lacking PPAR, a considerably prolonged inammatory response was observed, and this was suggested to be due to degradation of the chemotatic inammatory mediator, leukotriene B4 (Devchand et al., 1996). Increasing evidence suggests that PPAR may mediate its anti-inammatory actions through reduced generation of cytokines. This may occur secondary to downregulation of the activity of nuclear factor-kappa B (NF-B) and inducible cyclooxygenase-2 (COX-2) (Poynter & Daynes, 1998; Staels et al., 1998). PPAR-induced peroxisome proliferation has been associated with the development of hepatic carcinomas in rodents, possibly due to increased production of H2O2 in the absence of a compensatory rise in catalase activity (Gonzalez et al., 1998). However, this is likely to be of little clinical relevance due to the absence of peroxisome proliferation in humans upon PPAR activation. Furthermore, the concentration of PPAR agonist required to stimulate lipid metabolism (as desired with brate treatment) would be too low to stimulate the transcriptional induction of genes involved in peroxisome proliferation (Chevalier & Roberts, 1998). 1.7.2. PPAR PPAR acts as a primary regulator of adipocyte differentiation in the process of adipogenesis. Once fully matured, adipocytes are capable of producing various hormones and cytokines, in addition to

the uptake and storage of lipids. Activation of PPAR upregulates the expression of genes involved in fatty acid uptake and lipogenesis as well as glucose transporters (Shimaya et al., 1998). PPAR activation also promotes apoptosis in mature adipocytes, resulting in stimulation of adipogenesis and the formation of small insulin-sensitive adipocytes (Okuno et al., 1998). This is one potential mechanism by which thiazolidinediones may improve insulin sensitivity in diabetes. PPAR is known to regulate many genes involved in insulin signalling, such as those that control the expression of the pro-inammatory cytokine, tumour necrosis factor (TNF). PPAR activation signicantly reduces the production of TNF by adipocytes, which plays an established role in the development of insulin resistance (Moller, 2000). In diabetes, PPAR improves overall glucose homeostasis by increasing glucose transport in adipocytes, regulating adipocytederived hormone release, decreasing glucose formation and increasing glucose disposal in skeletal muscle (Kota et al., 2005). A recent study by Odegaard et al. (2007) has suggested that macrophagespecic PPAR activation also reduces insulin resistance in adipose tissue via differentiation of alternatively activated monocytes with an anti-inammatory phenotype. Indeed, PPAR, like PPAR, appears to exert signicant anti-inammatory effects. PPAR expression is markedly increased in activated macrophages, and stimulation of these upregulated receptors by the PPAR activator PGJ2, has been shown to inhibit the activity of NF-B, STAT and activator protein-1 (AP-1). These transcription factors are all known to increase the expression of genes encoding pro-inammatory cytokines (Ricote et al., 1998a), production of which has also been demonstrated to be reduced by PPAR activation in human monocytes (Jiang et al., 1998). Non-steroidal anti-inammatory drugs, such as ibuprofen and diclofenac, can activate PPAR at concentrations higher than those required for their characteristic COX activity. This activation has also been associated with the inhibition of cytokine production from monocytes, suggesting that endogenous intermediates which normally activate the COX pathway may potentially exert an additional opposing anti-inammatory role through activation of PPAR. The fact that PPAR activation stimulates cellular differentiation and apoptosis suggests that this approach may be benecial in the treatment of cancers. Indeed, PPAR agonists have been demonstrated to have potent anti-tumour effects in breast (Mueller et al., 1998), prostate (Kubota et al., 1998) colon (Jackson et al., 2003) and gastric (Sato et al., 2000) malignancies in both isolated cell and whole animal studies. However, it is not yet known whether these benets extend to the clinical arena. 1.7.3. PPAR Due to the ubiquitous nature of the expression of PPAR, it has been implicated in a variety of physiological and pathophysiological processes. Like PPAR and , PPAR plays a role in the regulation of circulating lipid and glucose levels (Berger et al., 1999). PPAR has also been suggested to modulate insulin resistance through activation of alternatively activated macrophages which inhibit inammation in both adipose tissue and liver (Kang et al., 2008; Odegaard et al., 2008). Furthermore, it appears likely that PPAR activation may be involved in fertility and pregnancy, as PPAR is highly expressed in implantation sites within the uterus (Lim et al., 1999; Ding et al., 2003). PPAR was initially implicated in tumour development (Gupta et al., 2000), but more recent work suggests that activation of PPAR may in fact attenuate carcinogenesis (Harman et al., 2004). The fact that PPAR is highly expressed in the central nervous system has generated much interest in a potential role in neural pathologies, and this is the subject of ongoing research. 2. PPARs and the cardiovascular system PPARs are widely expressed in both the vasculature and the myocardium, as well as in immune cells such as monocytes and

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263

251

macrophages. In addition to their role in transcriptional activation, in the unbound state, PPAR-RXR heterodimers can also repress target gene expression. Hence, PPARs can exert positive and negative regulatory control over a range of genes involved in metabolism and inammation (Bensinger & Tontonoz, 2008). As a result, their impact on cardiovascular (patho)physiology stretches far beyond their established effects on carbohydrate and lipid metabolism. This section will discuss the involvement of different PPAR isoforms in various cardiovascular pathologies and highlight how therapeutic activation of PPARs may prove benecial in preventing the development and progression of CVD. 2.1. Atherosclerosis Atherosclerotic vascular disease is one of the leading causes of mortality in the western world. It is principally an inammatory disease characterised by high plasma concentrations of cholesterol, particularly in the form of LDL. As elevated circulating lipids have long been established as the principal risk factor for the development of atherosclerosis, it was originally thought to be a process mainly consisting of the accumulation of lipids within the artery wall. However, it is now known to be a much more complex and multifaceted disease. Atherosclerotic lesions occur in large and medium-sized arteries as a result of increased lipid levels, hypertension, increased free radicals (e.g. from smoking) and diabetes. Their formation is triggered by endothelial cell activation and dysfunction causing the release of vasoactive molecules and cytokines, which stimulate an inammatory response and recruitment/migration of leukocytes into the arterial wall (Ross, 1999). Leukocyte migration relies on the interaction between endothelial cell adhesion molecules, such as vascular cell adhesion molecule-1 (VCAM-1), intracellular adhesion molecule-1 (ICAM-1), E-selectin and P-selectin, and their cognate ligands on circulating monocytes (Faggiotto et al., 1984; Springer, 1994). Increased expression of adhesion molecules within the atherosclerotic lesion stimulates monocyte recruitment and transmigration into the arterial intima, and accumulation of lipids and extracellular matrix may further amplify the local inammatory response (Van der Wal et al., 1992). Once within the subendothelial space, monocytes rapidly mature into tissue macrophages which take up oxidised lipoproteins via scavenger receptors (Goldstein et al., 1979; Brown & Goldstein, 1990). Intracellular accumulation of cholesterol results in the characteristic formation of foam cells and stimulates macrophages to secrete cytokines, growth factors and other mediators that promote smooth muscle cell proliferation and potentiate the inammatory response, leading to arterial remodeling (Brown & Goldstein, 1983). Apoptosis of macrophages and smooth muscle cells then occurs, which further enhances cytokine release. A continuing cycle of inammation and cell inltration causes progressive enlargement of the plaque, which protrudes into the arterial lumen blocking normal blood ow. Eventually, the plaque ruptures due to degradation by macrophageinduced matrix metalloproteinases (MMPs) and hydrolytic enzymes, resulting in thrombus formation and tissue infarction (Libby et al., 1996; Ross, 1999). The combined inuence of lipid dysregulation and inammation in atherogenesis strongly implies that PPARs, which positively inuence both processes, may play a benecial role in attenuating the development of this disease. 2.1.1. PPAR in atherosclerosis Endothelial cells (Inoue et al., 1998), vascular smooth muscle cells (Staels et al., 1998) and monocytes/macrophages (Chinetti et al., 1998) are all known to express PPAR. In atherosclerosis, activation of PPAR in these cells acts to reduce leukocyte recruitment, cell adhesion, inammation and injury. Endothelial activation of PPAR has been demonstrated to downregulate cytokine-induced genes, such as VCAM-1 and tissue factor, and to inhibit the release of

monocytic chemotactic protein-1 (MCP-1), resulting in reduced inammatory cell adhesion and attenuation of atheroma development (Marx et al., 1999; Marx et al., 2000). A conicting study reported that PPAR activation increased production of MCP-1 from endothelial cells, suggesting a pro-inammatory role for PPAR (Lee et al., 2000). However, the consensus from the majority of studies examining the endothelial actions of PPAR agonists appears to be that PPAR stimulation exerts positive anti-inammatory effects. In addition to inhibiting the inammatory response, PPAR agonists can also modify the release of vasoactive mediators, such as endothelin-1 (ET-1) (Delerive et al., 1999a) and nitric oxide (NO) (Goya et al., 2004) from the endothelium, to favour vasodilatation. It is likely that ET-1 is involved in atherogenesis as it is capable of inducing both vascular smooth muscle cell proliferation and endothelial cell adhesion molecules (McCarron et al., 1993) and also exerts chemotactic properties on monocytes (Achmad & Rao, 1992). Indeed, ET-1 is highly expressed in atherosclerotic lesions and inhibition of ET-1 by PPAR agonists not only improves endothelial function but also reduces inammation (Jones et al., 1996). In vascular smooth muscle cells the anti-inammatory actions of PPAR can be demonstrated by PPAR agonist-induced inhibition of interleukin-1 (IL-1)-stimulated IL-6 production, prostaglandin synthesis and COX-2 induction, effects which have been shown to occur secondary to downregulation of NF-B and induction of p38MAPKdependent apoptosis (Chinetti et al., 1998; Staels et al., 1998; Diep et al., 2000). PPAR activators have also been found to attenuate atherosclerotic vascular remodeling by inhibiting smooth muscle cell proliferation and migration (Delerive et al., 1999b). Furthermore, vascular smooth muscle cell migration and atherogenic plaque destabilisation may be prevented by PPAR-dependent inhibition of macrophage MMP-9 expression (Marx et al., 1998; Shu et al., 2000). Activated PPAR not only inuences vascular inammation, reactivity and remodeling, but can also positively alter macrophage lipid handling within the plaque itself. PPAR activation has been shown to reduce macrophage triglyceride accumulation and to promote redistribution of cholesterol from intracellular stores to the plasma membrane, making it available for HDL-dependent efux and reverse transport (Chinetti et al., 2001; Haraguchi et al., 2003; Chinetti-Gbaguidi et al., 2005b). In human macrophages, PPAR-mediated inhibition of lipoprotein lipase secretion results in reduced uptake of glycated lipoprotein by these cells (Gbaguidi et al., 2002). In addition to modifying macrophage cholesterol transport, PPAR can also induce nicotinamide adenosine dinucleotide phosphate (NADPH) oxidasedependent reactive oxygen species (ROS) production, stimulating modication of LDL and enabling it to act as a PPAR ligand to further inhibit the induction of inammatory mediators (Teissier et al., 2004). Despite the overwhelming evidence supporting a benecial role for PPAR in atherosclerosis, preliminary studies in PPAR null mice suggest that these animals are actually protected against disease development (Tordjman et al., 2001; Tordjman et al., 2007). However, it is possible that these conicting ndings may not have been related to the absence of PPAR, but to unintended disruption of one or more other genes (Yagil & Yagil, 2007). Further research is needed to resolve this issue and conrm the protective role of PPAR in atherosclerosis. 2.1.2. PPAR and atherosclerosis PPAR has a similar vascular prole to PPAR, with signicant expression in endothelial cells (Satoh et al., 1999), smooth muscle cells (Law et al., 2000) and monocytes/macrophages (Ricote et al., 1998b), and has many similar actions. Signicant levels of PPAR have been found in atherosclerotic lesions and its activation reduces monocyte recruitment by the plaque (Marx et al., 1998). In endothelial cells, PPAR activation has several benecial actions on the inammatory response, including inhibition of TNF and MCP-1 and attenuation of TNF-induced expression of VCAM-1 and ICAM-1 (Lee et al., 2000; Pasceri et al., 2000; Bruemmer et al., 2005). Like

252

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263

PPAR, PPAR also inhibits endothelial ET-1 production (Delerive et al., 1999a) and stimulates NO release (Calnek et al., 2003), resulting in both vasodilatation and improved endothelial cell function. In macrophages, PPAR agonists have been demonstrated to both increase PPAR expression and inhibit MMP synthesis (Ricote et al., 1999), which contributes to their inhibitory effects on smooth muscle cell proliferation. In addition, PPAR ligands are known to inhibit monocyte/macrophage production of other inammatory cytokines, such as IL-6, IL-1 and TNF, by decreasing the activity of transcription factors, such as NF-B (Jiang et al., 1998). In vascular smooth muscle, PPAR agonists also attenuate cell migration and proliferation (Law et al., 2000). Supportive evidence for a benecial anti-inammatory role of PPAR in atherosclerosis is provided by a study using an experimental mouse model, in which PPAR agonists were found to limit intimal hyperplasia and reduce lesion size and inammation (Law et al., 1996). Although the majority of studies support a benecial effect of PPAR in atherogenesis, some investigators have suggested that PPAR may be deleterious in this situation. PPAR has been found to stimulate genes involved in cholesterol uptake by macrophages, such as CD36, and this process may be accentuated by further activation of PPAR by oxidised LDL (Nagy et al., 1998; Han et al., 2000). This implies that PPAR may promote foam cell formation; however, macrophage cholesterol content is not increased by PPAR agonists in the presence of acelytated LDL (Chinetti et al., 2001). Furthermore, it has been demonstrated that PPAR ligands can signicantly inhibit the development of atherosclerosis, in spite of elevated levels of CD36 in the arterial wall (Li et al., 2000). Activated PPAR has been shown to reduce macrophage triglyceride accumulation, lipoprotein secretion and glycated lipoprotein uptake, whilst enhancing HDL-dependent cholesterol efux and reverse cholesterol transport (Akiyama et al., 2002; Gbaguidi et al., 2002; Haraguchi et al., 2003). These studies add further complexity to an already complicated picture; how can PPAR activation increase CD36 in the absence of a concomitant increase in macrophage LDL? The unied model (Zhang & Chawla, 2004) links these two conicting arguments by suggesting that PPAR reduces accumulation of atherogenic oxidised LDL in the vessel wall by increasing both macrophage uptake and efux via upregulation of CD36. In light of all available evidence, this theory seems to be the most plausible and supports the benecial effects of PPAR in atherosclerosis. A recent study by Babaev et al. (2005) employing gene-modied mice provides additional evidence to support the suggestion that PPAR-mediated immune cell modulation is benecial in atherosclerosis. In this study macrophage-specic deletion of PPAR resulted in a marked increase in atherosclerosis development suggesting that PPAR-mediated macrophage activation is protective in this pathology. Recent studies have subsequently revealed the importance of the PPAR as a key regulator of macrophage activity and function (Majai et al., 2007; Odegaard et al., 2007). Furthermore, in human atherosclerotic lesions PPAR activation has been reported to promote differentiation of proatherogenic M1 macrophages into an alternative anti-inammatory phenotype, M2, which could protect against the development of atherosclerosis (Bouhlel et al., 2007). A denitive role for PPAR in atherogenesis could potentially be established with further studies in gene-modied mice such as the global PPAR/ or the endothelial cell-specic PPAR/. Development of a vascular smooth muscle cell-specic PPAR/ mouse would also signicantly aid the identication of the role of PPAR in atherosclerosis (Duan et al., 2008). 2.1.3. PPAR and atherosclerosis The ubiquitous nature of PPAR expression suggests that its activation may play a role in the development of atherosclerosis. Indeed, recent research has extended beyond the more established effects of PPAR and to begin to focus on PPAR, which also appears to exert benecial actions on atherogenesis. In a mouse model of

atherosclerosis, PPAR activation has been found to decrease expression of MCP-1, ICAM-1 and inammatory cytokines and to attenuate disease development (Li et al., 2004; Graham et al., 2005). In the macrophage, PPAR activation reduces circulating levels of proinammatory cytokines and TNF expression and has a positive effect on lipid handling by promoting cholesterol efux, reverse cholesterol transport and fatty acid catabolism (Oliver et al., 2001; Graham et al., 2005; Lee et al., 2006). Early work therefore suggests that activation of PPAR may be of potential therapeutic benet in the treatment of atherosclerosis. However, more detailed studies are required in order to dene its precise role in disease development and progression. 2.2. Hypertension Chronic hypertension is a primary risk factor for CVD, particularly atherosclerosis and heart failure (Zahradka, 2007). Despite improved medical treatments, its incidence is rapidly increasing and is set to reach epidemic proportions. Several factors inuence the development of hypertension, including age, gender, the existence of associated conditions such as diabetes and obesity, and lifestyle factors such as alcohol consumption and smoking. The development of pathological hypertension usually occurs secondary to endothelial dysfunction and an imbalance between vasoconstrictors, such as angiotensin II (Ang II) and ET-1, and vasodilators, such as NO (Schulman et al., 2006). Atherosclerosis itself can also cause hypertension due to protrusion of the lesion into the lumen, resulting in narrowing of the blood vessel, which cannot be counteracted by local vasorelaxant mechanisms (Ross, 1999). To date the role of the different PPAR isoforms in hypertension have been examined in a number of commonly used experimental models. These include (1) the deoxyycorticosterone acetate (DOCA)salt model, which is associated with enhanced expression of preproET-1; (2) the spontaneously hypertensive rat (SHR), in which a genetic mutation results in alteration of the reninangiotensin aldosterone system, causing sodium retention and elevated blood pressure in the absence of concomitant obesity and diabetes (Kobori et al., 2005); (3) chronic Ang II infusion. Interestingly, PPAR agonists have been demonstrated to have direct vasorelaxant effects (Goya et al., 2004), suggesting that they may hold therapeutic potential as effective anti-hypertensive agents. 2.2.1. PPAR and hypertension PPAR is widely expressed in all vascular cell types suggesting that its activation may be involved in the control of blood pressure by modulation of vascular tone. Indeed, PPAR-dependent regulation of blood pressure has been demonstrated in each of the aforementioned experimental models of hypertension. In Ang II-infused rats, the PPAR agonist, docosahexaenoic acid (DHA) was found to reduce blood pressure and attenuate vascular remodeling, possibly by inhibiting the development of NADPH oxidase-induced endothelial dysfunction (Diep et al., 2002a). In the same experimental model, the PPAR agonist, fenobrate-induced a signicant decrease in blood pressure which was associated with reduced expression of vascular inammatory mediators (Diep et al., 2004). However, in the DOCAsalt model of hypertension, fenobrate failed to normalise mean arterial blood pressure, despite PPAR activation causing a signicant reduction in NADPH oxidase-dependent superoxide generation (Iglarz et al., 2003). Interestingly, clobrate was also found to inhibit NADPH oxidase activity in this model, but in contrast to fenobrate, signicantly reduced blood pressure, an effect which was attributed to inhibition of endothelial ET-1 production (Delerive et al., 1999a; Newaz et al., 2005). In the SHR, increased PPAR expression has been found in both whole blood vessels and cultured vascular smooth muscle cells from these animals (Diep & Schiffrin, 2001). In this model, chronic PPAR activation with fenobrate has also been demonstrated to be associated with a reduction in systolic blood

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263

253

pressure (Li et al., 2008), although other investigators have failed to report anti-hypertensive effects (Wu et al., 2004). Studies using PPAR/ mice have produced conicting ndings in regard to its role in blood pressure regulation. Deletion of PPAR has been shown to signicantly increase (Newaz et al., 2005), decrease (Guellich et al., 2007) and have no signicant effect (Loichot et al., 2006) on systolic blood pressure compared with wild-type controls. Interestingly, Newaz et al. (2005) found that the increased blood pressure in their PPAR/ mice could be abolished by the NO synthase (NOS) inhibitor, N-nitro-L-arginine methyl ester (L-NAME), suggesting that PPAR may modulate endothelial NO production (Goya et al., 2004). 2.2.2. PPAR and hypertension PPAR is expressed in vascular smooth muscle and endothelial cells, and glitazone-induced activation has been found to exert blood pressure-lowering effects in insulin-resistant fatty Zucker rats, although the mechanisms of action were unclear (Walker et al., 1999). In Ang II-induced hypertension, the PPAR agonists, pioglitazone and rosiglitazone caused a signicant decrease in blood pressure, in addition to benecial actions on cell growth, endothelial function and vascular inammation. These effects were found to be mediated via inhibition of DNA synthesis, NF-B activity, and endothelial/ platelet adhesion molecule expression (Diep et al., 2002b). It has also been suggested that the apparent hypotensive effects of PPAR agonists in this model may result from downregulation of the Ang II type 1 receptor (Sugawara et al., 2001). More recently, investigators have begun to examine how PPAR agonists directly affect the renin angiotensin system, with initial studies suggesting that PPAR activation stimulates renin gene expression (Todorov et al., 2007). This could potentially lead to increased Ang II production with a resultant increase in blood pressure, but is contradictory to the benecial hypotensive effects previously observed with PPAR agonists. One possible explanation could be that a delicate balance exists in the vasculature between the benecial effects of PPAR and the deleterious inuence of the reninangiotensin system, so tipping the balance in favour of the latter could potentially be a key factor underlying the development of hypertension (Weatherford et al., 2007). In DOCA-salt hypertensive rats, mean arterial blood pressure was also normalised by administration of rosiglitazone, an effect which was not seen with the PPAR agonist, fenobrate (Iglarz et al., 2003). However, both PPAR activators were found to attenuate the increased preproET-1 expression and concentric hypertrophy which are characteristic of this model. Although only the PPAR agonist prevented hypertensive endothelial dysfunction, both agonists were found to signicantly reduce ROS production, implying that this is not the primary mechanism underlying impaired vascular function in this model. PPAR has also been shown to antagonise endothelial ET-1 secretion, so its anti-hypertensive effects in this ET-1-dependent model of hypertension are maybe not surprising (Satoh et al., 1999). In the SHR, the PPAR agonist, pioglitazone has been demonstrated to lower blood pressure (Verma et al., 1998; Grinsell et al., 2000). However, when these animals were treated with a NOS inhibitor, LNAME, effects on blood pressure, metabolism and serum NO levels were no longer evident, although pioglitazone did prevent vascular inammation and the development of atherosclerosis (Ishibashi et al., 2002). Furthermore, administration of ciglitazone to SHRs has been found to ameliorate vascular endothelial dysfunction via increased NOS activity (Smiley et al., 2004), supporting the suggestion that stimulation of NO production is essential to this PPAR-mediated reduction of blood pressure. It has previously been suggested that downregulation of PPAR may be responsible for the vascular proliferation, migration, inammation and brosis found in the SHR (Schiffrin, 2005). Indeed, vascular expression of PPAR proteins was found to be reduced at 21 weeks in this model, compared to age-matched wild-type animals,

although at a younger age (513 weeks) no signicant difference was detected (Wu et al., 2004). Treatment with the PPAR agonist, rosiglitazone from 513 weeks, attenuated the subsequent development of, hypertension, although PPAR activation had no signicant effect (Wu et al., 2004). However, PPAR activation in the SHR, whilst conferring benecial effects on blood pressure, was also found to be associated with left ventricular (LV) hypertrophy. In contrast to this study, there are previous reports of increased vascular expression of both PPAR and in SHR's at 16 weeks (Diep & Schiffrin, 2001), so the precise role of PPAR in this model is far from certain. Taken together, it appears that PPAR attenuates the development of hypertension via a mechanism involving increased NO production, reduced ET-1 secretion and inhibition of NADPH oxidase. However, the potential clinical benet may be limited by side effects such as weight gain, oedema, headache and visual disturbances which are commonly associated with PPAR receptor agonists. The effect of PPAR deletion on blood pressure has recently been examined in the newly developed generalised PPAR/ mouse, in which the embryonic lethality of global PPAR deletion was rescued by preserving trophoblastic PPAR expression (Duan et al., 2007). These mice were found to exhibit hypotension, which was resistant to correction by high salt loading. Further ex vivo studies revealed that the vasculature of these animals was more sensitive to endotheliumdependent relaxation caused by muscarinic stimulation (in the absence of changes in endothelial NOS expression or phosphorylation) and less responsive to -adrenergic contractile agents, leading the authors to conclude that the hypotension observed in these PPAR/ mice occurred via a mechanism involving increased vascular relaxation. Whilst previous studies have reported PPAR activation to also cause hypotension (Grinsell et al., 2000; Duan et al., 2007), this was found to occur in the presence of increased endothelial NOS expression which was not observed in vessels from generalised PPAR/ mice. Interestingly, this may suggest that PPAR is capable of modulating blood pressure via divergent mechanisms, although more detailed studies in the generalised PPAR/ are clearly required to further investigate this possibility. 2.2.3. PPAR and hypertension Despite the recent discovery of specic PPAR ligands, such as L165041 and GW0742X, the role of PPAR in the regulation of vascular tone and development of hypertension remains unknown. 2.3. Cardiac ischaemiareperfusion Chronic heart failure affects up to 2% of the adult population in the western world, the most common cause of which is myocardial infarction (MI). MI results from coronary artery occlusion, usually occurring after atherosclerotic plaque rupture. This causes ischaemia of the cardiac muscle, the severity of which varies depending on the location of the occlusion within the coronary vasculature. Prolonged ischaemia leads to cardiomyocyte death which is followed by a series of structural and functional alterations in the viable myocardium, known as cardiac remodeling. In particular, adaptive changes in the extracellular matrix and in cardiomyocyte biology occur, which are initially able to maintain contractile function. However, progressive cardiac remodeling leads to chamber dilatation, contractile dysfunction and ultimately heart failure (Snghedauw, 1999). The resultant metabolic changes may also lead to the development of potentially life-threatening arrhythmias. Myocardial reperfusion is the standard rst-line treatment in acute MI, aiming to restore blood ow to the ischaemic myocardium and promote tissue survival. However, reperfusion itself has been found to exacerbate ischaemic damage, causing further depression of cardiac function (Piper et al., 2003). Various experimental models have been employed to study either myocardial ischaemia with subsequent reperfusion or cardiac remodeling associated with chronic MI.

254

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263

Inltration of neutrophils and macrophages is known to enhance the inammatory response to myocardial ischaemia (Frangogiannis et al., 2002) and in combination with rapid accumulation of ROS within the ischaemic zone can lead to tissue necrosis upon reperfusion (Li et al., 1999). This is further amplied by activation of redoxsensitive transcription factors, such as NF-B and AP-1, which control the expression of pro-inammatory mediators, such as IL-12 and TNF. Indeed, in an experimental rat model, inhibition of NF-B has been demonstrated to reduce reperfusion injury after a brief period of ischaemia (Onai et al., 2004). Furthermore, upregulation of AP-1 has been observed in cardiomyocytes in the presence of increased levels of ROS (Aggeli et al., 2006), such as those observed during ischaemia and reperfusion, suggesting that this transcription factor may be involved in the pathogenesis of ischaemia and subsequent reperfusion. Interestingly, PPARs have been shown to exert their anti-inammatory effects via NF-B and AP-1 inhibition, suggesting a potential mechanism by which agonists of these receptors may be benecial in attenuating ischaemiareperfusion injury (Chinetti et al., 1998; Dragomir et al., 2006; Smeets et al., 2007). 2.3.1. PPAR and cardiac ischaemiareperfusion PPAR is abundantly expressed in the heart, where it plays an important role in the regulation of fatty acid oxidation by inducing the expression of genes encoding proteins involved in fatty acid uptake and metabolism. Under normal physiological conditions, fatty acids act as the primary energy source for adult cardiomyocytes. In the ischaemic myocardium and after reperfusion PPAR has been found to be downregulated, although it is unclear whether this is a benecial or detrimental adaptation (Dewald et al., 2005). In an attempt to clarify the precise role of PPAR in ischaemiareperfusion and establish whether PPAR ligands may be benecial in its treatment, many studies have examined their effects in various experimental models of ischaemia and/or reperfusion. Overall, PPAR appears to have a benecial effect in ischaemia reperfusion. In an in vivo rat model of ischaemiareperfusion, infusion of the PPAR agonist, Wy 14,643 prior to coronary artery occlusion resulted in a signicant decrease in infarct size, which was associated with increased myocardial contractility (Wayman et al., 2002a; Bulhak et al., 2006), suggesting that PPAR activation may attenuate the depression of cardiac function that typically occurs during reperfusion (Yeh et al., 2006). The cardioprotective effect of PPAR activation has been linked to inhibition of the NF-B pathway (Yue et al., 2003; Yeh et al., 2006) and the associated decrease in expression of inammatory mediators. Another PPAR agonist, GW7647 has also been demonstrated to signicantly reduce infarct size in a mouse model of ischaemiareperfusion (Yue et al., 2003). This positive effect on ischaemiareperfusion was abolished in PPAR/ mice, suggesting that it occurs through direct activation of the receptor. Administration of the brates, clobrate (Wayman et al., 2002b; Tian et al., 2006) and fenobrate (Tabernero et al., 2002) have also been shown to have benecial effects in ischaemiareperfusion both ex vivo and in vivo, adding further support to the idea that PPAR activation may be cardioprotective. Despite the widely reported benecial effects of Wy 14,643 in ischaemiareperfusion, a conicting study has demonstrated that it is associated with negative effects in an in vivo mouse model of repetitive ischaemiareperfusion (Dewald et al., 2005). However, signicant differences between the time course, metabolic effects and mechanisms underlying ischaemic injury in this model compared with the single ischaemic insult employed by most studies, may account for the lack of effect of the PPAR agonist. Findings from PPAR gene-modied mice are also somewhat contradictory. For example, whereas the presence of PPAR has been found to be benecial in preserving cardiac function in ischaemiareperfusion (Tabernero et al., 2002), isolated perfused hearts from PPAR/ mice demonstrated improved function after ischaemia (Panagia et al.,

2005; Sambandam et al., 2006) and those from animals overexpressing PPAR exhibited reduced recovery (Sambandam et al., 2006). Furthermore, some investigators have demonstrated a positive effect of PPAR ligands against hypoxic damage (Wayman et al., 2002a,b; Bulhak et al., 2006), whilst others have reported that they have no signicant effect on (Aasum et al., 2003) or are deleterious to (Sambandam et al., 2006) cardiac functional recovery after ischaemia. A likely explanation for these conicting ndings appears to be the choice of experimental model, as in general, in vivo studies have tended to show PPAR agonists to exert cardioprotective effects, whereas ex vivo studies have produced varying results. The isolated heart preparation, for example, is not subject to the neurohumoral inuences experienced in vivo and the use of pharmacological PPAR agonists versus PPAR gene-modied animals may also contribute to the diversity of experimental ndings. 2.3.2. PPAR and cardiac ischaemiareperfusion As PPAR is predominantly expressed in adipocytes, the majority of studies have tended to focus on its predominant role in lipid metabolism. As such, the precise physiological role of PPAR in the myocardium has yet to be fully established. PPAR has, however, been found to be expressed in rat heart and PPAR agonists have been shown to reduce myocardial infarct size (Wayman et al., 2002b). Overall, the ndings from studies on the effects of PPAR activation in ischaemiareperfusion are much more consistent than those found with PPAR, suggesting that PPAR agonists may be of greater potential therapeutic benet in this setting. Studies employing chemically different ligands to activate PPAR, such as the thiazolidinediones (rosiglitazone, troglitazone, pioglitazone and ciglitazone) and prostaglandins (15d-PGJ2 and PGA1) have demonstrated signicant reduction in infarct size and improvement of myocardial function. Rosiglitazone has been shown to reduce infarct size in various in vivo (Yue et al., 2001; Wayman et al., 2002b; Liu et al., 2004; Molavi et al., 2006) and ex vivo (Khandoudi et al., 2002; Sidell et al., 2002) experimental models of ischaemiareperfusion. Furthermore, signicant recovery of LV developed pressure has been observed during post-ischaemic reperfusion after rosiglitazone treatment (Gonon et al., 2007). Pioglitazone and ciglitazone have been found to exert similar positive effects to rosiglitazone in all models of ischaemiareperfusion, causing signicant infarct size reduction and improved cardiac function (Wayman et al., 2002b; Ito et al., 2003; Sivarajah et al., 2005; Wynne et al., 2005; Zingarelli et al., 2007). In an in vivo pig model of myocardial ischaemiareperfusion, the PPAR agonist troglitazone was found to improve recovery of LV systolic and diastolic function (Zhu et al., 2000), a nding which is supported by similar studies using other animal models (Shimabukuro et al., 1996; Lee & Chou, 2003). In addition, the high afnity endogenous ligand for PPAR, 15d-PGJ2 (which also has PPAR-independent actions; Kaplan et al., 2007), has been found to reduce infarct size and improve cardiac functional recovery after ischaemia, which suggests that the effects of PPAR agonists are mediated via a direct action on the receptor. Indeed, inhibition of PPAR with the specic receptor antagonist, GW9662, results in a signicant increase in infarct size following ischaemiareperfusion (Sivarajah et al., 2005). However, in contrast to the majority of evidence implying that thiazolidinediones are benecial in ischaemiareperfusion, troglitazone was shown to signicantly increase the incidence of ventricular arrhythmias during a period of 90 min ischaemia followed by the same duration of reperfusion in an in vivo pig model (Xu et al., 2003). Several different mechanisms have been suggested to mediate the cardioprotective effects of PPAR, such as inhibition of NF-B, (Wayman et al., 2002b), reduced inltration of leukocytes (Yue et al, 2001; Ito et al., 2003) and inhibition of apoptosis (Liu et al., 2004). PPAR agonists have been demonstrated to rapidly induce their cardioprotective effects, within minutes of administration, and a bolus dose of ligand prior to ischaemia is just as effective in

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263

255

attenuating myocardial injury as continual infusion. These observations suggest that the benecial effects of PPAR activation in ischaemiareperfusion are not mediated through longer-term alterations in gene expression, although they may occur secondary to their anti-inammatory actions. Few studies have examined the effects of PPAR ( or ) activation in experimental models of chronic MI, in which permanent coronary artery occlusion leads to cardiomyocyte death within the ischemic zone and remodeling of the viable myocardium. Those which have done have produced conicting ndings. For example, the PPAR agonist, fenobrate has been found to accelerate the development of LV hypertrophy (Morgan et al., 2006), whereas the PPAR agonist, rosiglitazone has been reported to both increase mortality (Lygate et al., 2003) and improve myocardial remodeling (Geng et al., 2006). It is possible that these inconsistent results may be due to differences in experimental study design. Nonetheless, signicant further research is required in order to delineate the precise role of PPARs in chronic ischaemic remodeling. 2.3.3. PPAR and cardiac ischaemiareperfusion Despite the preponderance of evidence suggesting that activation of PPAR and is cardioprotective in ischaemiareperfusion, the role of PPAR has yet to be established. 2.4. Cardiac hypertrophy LV hypertrophy is an independent risk factor for heart failure, arrhythmia and sudden death and is one of the most potent predictors of adverse cardiovascular outcomes in hypertensive patients (Healey & Connolly, 2003; Gradman & Alfayoumi, 2006). It is characterised by maladaptive changes in myocardial structure and function, which are collectively known as cardiac remodeling. The heart initially compensates for the increased wall stress by undergoing signicant alterations in cardiomyocyte biology and in the extracellular matrix. However, progressive LV hypertrophy combined with loss of collagen crosslinking and myocyte slippage causes increased wall stress leading to cardiac chamber dilatation, contractile dysfunction and ultimately decompensated congestive heart failure (Snghedauw, 1999; Frey & Olsen, 2003). Despite improved clinical management of hypertension with agents such as angiotensin-converting enzyme (ACE) inhibitors and -blockers, which attenuate cardiac remodeling and have morbidity/mortality benets, there remains a substantial incidence of heart failure even in optimally-treated patients (Francis & Young, 2001). A detailed understanding of the complex regulatory mechanisms underlying the pathogenesis of cardiac remodeling is therefore essential to inform the development of more effective treatments. The development of cardiac hypertrophy is inuenced by several factors such as age, weight and obesity. It may also develop in the absence of increases in blood pressure in patients with obesity and diabetes, where the heart acts to compensate for the loss of functional heart muscle through the effects of disease and injury (Otto et al., 2004). Changes in structure and function of the heart are mediated by a variety of mechanical, neuronal and hormonal factors. 2.4.1. PPAR and cardiac hypertrophy In the normal adult heart, fatty acids serve as the chief energy substrate (Taegtmeyer, 1994) as they are more efcient, providing a greater yield of ATP compared to either glucose or lactate. Circulating fatty acids are transported into the cardiomyocyte, where they are metabolised via mitochondrial -oxidation. In contrast, the fetal heart relies primarily on glucose and lactate due to its relatively hypoxic environment, as glycolytic production of ATP is more oxygen efcient than fatty acid metabolism. In the neonatal heart, the capacity for fatty acid oxidation rapidly increases in parallel with mitochondrial proliferation within the cardiomyocyte, establishing fatty acids as the primary source of ATP.

PPAR activation in the heart stimulates upregulation of genes controlling mitochondrial fatty acid uptake, which results in increased fatty acid metabolism and generation of ATP (Brandt et al., 1998; van der Lee et al., 2000a,b; Vosper et al., 2002). In the hypertensive heart, the increased demands on the myocardium trigger signicant alterations in energy metabolism. Both clinical and experimental studies in hypertrophied and failing hearts demonstrate a decrease in the expression of genes involved in fatty acid oxidation, with an increase in glucose oxidation, although in this setting the energy provided by this alternative source does not correspond to that previously supplied via fatty acid metabolism (Bishop & Altschuld, 1970; Christie & Rodgers, 1994; Takeyama et al., 1995; Sack et al., 1996). This reversion to the fetal genotype is a characteristic feature of cardiac hypertrophy, and occurs not only in genes involved in oxidative metabolism, but also in those controlling other aspects of cardiomyocyte biology. As PPAR is the principal regulator of myocardial fatty acid oxidation, it seems likely that the decreased expression of genes involved in fatty acid oxidation as observed in cardiac hypertrophy may be a consequence of altered PPAR activity or expression. PPAR was initially implicated in cardiac hypertrophy when children with congenital defects in fatty acid oxidation were found to develop the disease (Kelly & Strauss, 1994). In adults, variations in the genes encoding for PPAR have also been shown to inuence both physiological and pathological hypertrophic growth of the myocardium (Jamshidi et al., 2002). In a mouse model of pressure overloadinduced by transverse aortic constriction, Barger et al. (2000) reported downregulation of PPAR and several of its target genes in parallel with signicant increases in morphometric hypertrophy and atrial natriuretic factor (ANF) expression, suggesting that downregulation of PPAR may be responsible for reversion to the fetal metabolic genotype in the hypertrophied myocardium. Whether the altered activity of PPAR in hypertrophy is adaptive or indeed related to myocardial pathology has been the subject of intense debate. In pressure overload-induced cardiac hypertrophy, reversion to the fetal genotype is initially thought to be an adaptive and benecial response (Frey & Olsen, 2002), as glucose oxidation substitutes for fatty acid metabolism to reduce oxygen consumption. However, with progressive hypertrophy, reduced ATP production via the glucose oxidation pathway, results in cardiac contractile dysfunction and myocardial lipid accumulation and toxicity (Barger & Kelly, 2000). This suggests that although downregulation of PPAR may be initially benecial, it may also be maladaptive during the decompensated stage of cardiac hypertrophy. Many studies have attempted to clarify the precise role of PPAR in cardiac hypertrophy, but conicting ndings have only served to further confuse the issue. An early study employing a rat model of ascending aortic constriction for 7 days found that pharmacological reactivation of PPAR with Wy 14,643 had no signicant effect on morphological hypertrophy or induction of ANF (Young et al., 2001). Surprisingly, reactivation of PPAR in the hypertrophied heart also led to severe depression of cardiac power and efciency assessed ex vivo, suggesting that downregulation of PPAR may be a necessary adaptation to maintain myocardial function. Indeed, administration of Wy 14,643 was also found to cause a substantial decline in glucose oxidation, rather than the anticipated increase in fatty acid oxidation, which would result in myocardial energy starvation, thus accounting for the observed cardiac dysfunction (Young et al., 2001). In another study, normal rats fed with Wy 14,643 for 26 weeks were found to develop signicant morphometric cardiac hypertrophy, indicating that PPAR activation alone can act as a hypertrophic stimulus (Hamano et al., 2001). Furthermore, the same authors reported that co-application of Wy 14,643 and clobrate to a rat cardiomyocyte cell line signicantly increased transcription of the pro-hypertropic marker gene, myosin light chain-2, supporting their in vivo observation (Hamano et al., 2001). Cardiac-specic

256

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263

overexpression of PPAR in mice has also been demonstrated to be deleterious, resulting in signicantly reduced myocardial glucose oxidation. Interestingly, these mice, unlike the previously described rat models, exhibited increased fatty acid oxidation, although this was not sufcient to prevent cardiac dysfunction (Finck et al., 2002). This suggests that PPAR downregulation is benecial, but that overexpression of PPAR induces a complete reliance on fatty acid oxidation, leading to oxygen depletion and loss of normal function. However, the function of PPAR in this rather articial situation may not be indicative of its role at physiological expression levels. Although many studies have demonstrated a negative inuence of PPAR in cardiac hypertrophy, there are an increasing number of conicting reports indicating that PPAR activation may actually be benecial in this setting. In vivo activation of PPAR by fenobrate has been found to inhibit the development of myocardial brosis in rats subjected to pressure overload via inhibition of ET-1-mediated broblast proliferation (Ogata et al., 2002). Fenobrate treatment has also been found to attenuate the development of myocardial hypertrophy and brosis and to preserve in vivo contractile function in Dahl salt-sensitive rats, through inhibition of NF-B-mediated inammation (Ichihara et al., 2006). These effects were thought to occur via inhibition of the inammatory response through downregulation of NF-B, and deactivation of redox-regulated transcription factors and the subsequent reduction in ROS production. In DOCA-salt hypertensive rats overexpressing ET-1, Iglarz et al. (2003) conrmed that fenobrate administration signicantly attenuated cardiac brosis and remodeling, which was associated with decreased myocardial inammation. Activation of PPAR by fenobrate was also shown to inhibit ET-1-induced cardiac hypertrophy in isolated rat cardiomyocytes (Li et al., 2007), adding further weight to the suggestion that fenobrate-induced PPAR activation inhibits cardiac hypertrophy. Furthermore, in vitro studies using rat neonatal cardiomyocytes have reported fenobrate to inhibit ET-1-induced hypertrophy and protein synthesis (Liang et al., 2003; Irukayama-Tomobe et al., 2004) and Wy 14,643 to inhibit hypertrophy via inhibition of NF-B (Smeets et al., 2008a).

Studies using PPAR/ mice have predominantly shown that absence of the receptor is detrimental to cardiac function. A recent study by Smeets et al. (2008b) demonstrated that PPAR/ mice subjected to chronic pressure overload developed signicantly more pronounced cardiac hypertrophy and contractile dysfunction compared to wild-type controls. Other groups using the same mice have demonstrated that the absence of PPAR results in reduced myocardial brosis and ex vivo contractile dysfunction in isolated hearts, which was more susceptible to further deterioration but could be rescued by increasing cardiac glucose utilisation (Luptak et al., 2005; Loichot et al., 2006). It has also been reported that fenobrate treatment further exacerbates cardiac hypertrophy, brosis and remodeling in PPAR/ mice subjected to chronic pressure overload, whilst reducing remodeling in wild-type animals, indicating that PPAR agonists may exert deleterious effects which are independent of receptor activation (Duhaney et al., 2007). This may also explain the negative ndings in respect to pharmacological PPAR reactivation with Wy 14,643 in the hypertrophied myocardium. As all studies using fenobrate in wild-type animals have reported positive effects on cardiac hypertrophy, this suggests that the benecial actions of PPAR activation may outweigh any negative receptor-independent effects. The link between PPAR activation and inhibition of ROS which has been borne out by many of the pharmacological studies is supported by the ndings of another study in PPAR/ mice, in which myocardial expression of the ROS-scavenging enzyme, superoxide dismutase, was found to be signicantly reduced and associated with oxidative damage to cardiac myosin. The authors suggested that decreased superoxide dismutase activity may lead to elevated myocardial ROS production, which could be responsible for the impaired cardiac contractile function observed in PPAR/ mice (Guellich et al., 2007). The role of ROS and the downregulation of PPAR in hypertrophy development are illustrated in Fig. 4. Taken together, it appears that PPAR downregulation or absence of the receptor is detrimental in cardiac hypertrophy. Pharmacological reactivation of PPAR may attenuate the progression of hypertrophy and associated contractile dysfunction, although a more complete understanding of the receptor-independent actions of PPAR agonists

Fig. 4. Role of ROS and PPAR in the development of cardiac hypertrophy. The production of ROS and downregulation of PPAR (as a result of hypertension) initiates a series of intracellular responses which eventually lead to the development of myocardial hypertrophy and remodeling. It has been suggested that ROS may also stimulate the downregulation of PPAR, leading to decreased fatty acid oxidation and glucose metabolism which is characteristic of cardiac hypertrophy.

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263

257

is required before their potential therapeutic benet can be accurately assessed. 2.4.2. PPAR and cardiac hypertrophy Similar to PPAR, the precise involvement of PPAR in cardiac hypertrophy remains somewhat controversial. PPAR is known to be expressed at a low level in the heart (Escher & Wahli et al., 2000; Wayman et al., 2002b). Nonetheless, the majority of studies investigating the effects of PPAR agonists in cardiac hypertrophy suggest that they may play a protective role, although the mechanisms underlying these actions are unclear. Of note, agonists for PPAR have been found to have no signicant effect on cardiomyocyte expression of target genes involved in fatty acid oxidation (Barger & Kelly, 2000). Consistent with this nding, a study by Gilde et al. (2003) in rat neonatal cardiomyocytes revealed that the rate of fatty acid oxidation signicantly increased after exposure to PPAR and PPAR ligands, but not to PPAR ligands. Similarly, the fatty acid-mediated expression of fatty acid-handling proteins was mimicked by PPAR and PPAR but not by PPAR ligands. Furthermore, in adult rat cardiomyocytes activation of PPAR had no signicant effect on fatty acid metabolism but prevented cell hypertrophy, suggesting that inactivation of PPAR may enable the development of hypertrophy (Pellieux et al., 2007). Taken together, it appears that PPAR may not exert its cardiac effects via regulation of myocardial metabolism. Several studies employing various in vitro and in vivo experimental models have demonstrated that PPAR activation signicantly reduces the development of cardiac hypertrophy and brosis. Both the synthetic agonists of PPAR, the thiazolidinediones, and the endogenous activator, 15d-PGJ2, have been found to attenuate mechanical strain and ET-1-induced hypertrophy in neonatal cardiomyocytes, respectively (Yamamoto et al., 2001; Liang et al., 2003). This effect was shown to be mediated via PPAR-dependent inhibition of the NF-B pathway (Yamamoto et al., 2001) and could be reversed with a specic PPAR antagonist, leading to induction of the prohypertrophic marker gene, brain natriuretic peptide (BNP) (Liang et al., 2003). This latter observation implies that the benecial effects of PPAR agonists in cardiac hypertrophy could be due to direct receptor activation. Indeed, the heterozygous PPAR+/ mouse has been found to exhibit cardiac hypertrophy, which is further accentuated upon imposition of chronic pressure overload (Asakawa et al., 2002). Rosiglitazone has also been found to signicantly reduce cardiac remodeling and brosis in DOCA-salt hypertensive rats (Iglarz et al., 2003), as has ciglitazone in a mouse model of chronic pressure overload-induced by abdominal aortic constriction (Henderson et al., 2007). Ciglitazone also attenuated pressure overload-induced increases in the expression of the NADPH oxidase subunit, Nox4, suggesting a potential role for ROS in its cardioprotective actions (Henderson et al., 2007). Despite the large amount of evidence supporting a benecial role for PPAR in cardiac hypertrophy, several studies have reported contradictory ndings. In vivo administration of rosiglitazone was shown to accentuate the development of cardiac hypertrophy in SHRs (Wu et al., 2004). Furthermore, chronic treatment of normal rats with both the selective PPAR agonist, X334, and the novel thiazolidinedione, T-174, were found to induce cardiac hypertrophy (Arakawa et al., 2004; Edgley et al., 2006). However, in the latter study, this effect was attributed to an increase in blood volume following T-174 treatment, rather than a direct effect on the myocardium. Indeed, hypervolaemia and oedema are known to be common side effects of thiazolidinedione treatment (Edrmann & Wilcox, 2008), which may also account for the hypertrophic effects observed in the other two studies. Interestingly, rosiglitazone has been reported to induce cardiac hypertrophy in both cardiomyocyte-specic PPAR/ mice and wild-type littermate controls via activation of distinctly different pathways (Duan et al., 2005), indicating that the presence of PPAR in the myocardium may suppress the actions of trophic stimuli, and that

PPAR ligands could mediate their effects independently of PPAR. This suggestion is supported by an elegant study which employed both cardiomyocyte and macrophage-specic PPAR/ mice to investigate the effect of PPAR ligands on the development of angiotensin II (Ang II)-induced cardiac hypertrophy and brosis (Caglayan et al., 2008). Administration of the PPAR agonist, pioglitazone was found to promote Ang II-induced cardiac hypertrophy in both cardiomyocytespecic PPAR/ mice and wild-type littermate controls, whilst attenuating parallel increases in myocardial brosis, again indicating that PPAR ligands may exert their cardiac effects independently of PPAR. Furthermore, the benecial actions of pioglitazone on Ang IIinduced brosis were found to be absent in macrophage-specic PPAR/ mice, suggesting that macrophage PPAR-induced inhibition of myocardial macrophage inltration is critical to this effect. Previous studies relating to the effects of PPAR agonists on cardiac hypertrophy must therefore be interpreted with care given these PPAR-independent effects. Nonetheless, ndings from gene-modied mice are encouraging and suggest that PPAR may be benecial in preventing myocardial hypertrophy. It is possible that the future development of more specic PPAR agonists may reveal the true role of PPAR and unlock their therapeutic potential. 2.4.3. PPAR and cardiac hypertrophy PPAR is signicantly expressed in the myocardium (Gilde et al., 2003; Cheng et al., 2004a), where it has been reported to be involved in the transcriptional regulation of lipid metabolism (Barger & Kelly, 2000). However, to date, few studies have examined the role of PPAR in cardiac hypertrophy. Cardiomyocyte-specic PPAR/ mice have been shown to exhibit myocardial lipid accumulation, hypertrophy and heart failure with reduced survival (Cheng et al., 2004b), suggesting that PPAR may play a crucial role in maintaining normal cardiac function. Furthermore, in vitro activation of PPAR with both L-165041 and GW501516 was found to inhibit phenylephrine-induced hypertrophy of neonatal rat cardiomyocytes via inhibition of NF-B (Planavila et al., 2005; Smeets et al., 2008a). The positive ndings from these preliminary studies are encouraging, but signicant further investigation is required in order to identify the precise role of PPAR activation in cardiac hypertrophy. 2.5. Clinical implications Fibrates and thiazolidinediones are widely used in the treatment of hyperlipidaemia and type II diabetes, respectively. Although these are their primary indications due to positive effects on glucose homeostasis, lipid metabolism, atherogenic proteins, endothelial function, inammation and thrombosis, these compounds may also be of benet in other related pathologies, such as CVD (Verges, 2004). Indeed, recent attention has focussed on the potential use of PPAR agonists in the treatment of CVD, and how improvements in lipid balance, through continued treatment with these compounds, may benecially affect cardiovascular morbidity and mortality. First generation brates, such as clobrate, are known to be effective in lowering blood lipids with some studies revealing an associated reduction in the incidence of cardiovascular events (Vosper et al., 2002). This observation is supported by both the Helsinki Heart Study (Frick et al., 1987) and the Veterans Affairs HDL Intervention Trial (Rubins et al., 1999), in which treatment with the second generation brate, gembrizil, for 5 years was found to result in a 34% reduction in the cardiovascular event rate and a 22% decrease in mortality, respectively. Interestingly, subjects who had elevated circulating glucose levels and/or were overweight were found to benet most from gembrizil treatment (Tenkanen et al., 1995). More recently, the Fenobrate Intervention and Event Lowering in Diabetes (FIELD) study found that the incidence of non-fatal MI and cardiovascular mortality in patients with type II diabetes was not signicantly decreased by fenobrate treatment (Keech et al., 2005). However,

258

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263

secondary end points, such as stroke and vascular disease, were signicantly reduced, although the fact that this was not associated with a concomitant decrease in mortality brings the overall cardiovascular benet of long-term fenobrate therapy into question. PPAR agonists have also been employed in clinical trials to examine whether their known insulin-sensitising and anti-inammatory actions are benecial in CVD. In diabetic patients, pioglitazone therapy was found to cause a signicant reduction in all cause mortality, non-fatal MI and stroke (Dormandy et al., 2005) and to signicantly reduce carotid intima/media thickness, which is used as a measure of atherosclerotic vascular remodeling (Mazzone et al., 2006). However, the potential use of PPAR agonists in the treatment of CVD may be limited by profound side effects. Glitazone treatment has been associated with weight gain and peripheral oedema, which may precipitate an increased risk of heart failure (Lindberg & Astrup, 2007). More worryingly, a recent metaanalysis of clinical trials conducted in diabetic patients concluded that rosiglitazone treatment conferred an elevated risk of MI and cardiovascular mortality (Nissen & Wolski, 2007). At present, statins remain the drug of choice for the treatment and prevention of CVD, due to their benecial effects on cardiovascular mortality. Nonetheless, it is clear that PPAR agonists, such as brates and glitazones confer some favourable cardiovascular effects, especially in diabetic and/or obese individuals, and therefore hold therapeutic potential for the treatment of CVD. However, signicant further research is required in order to develop more specic drugs with reduced side effects which are able to compete with statins in terms of clinical outcome. 2.6. Dual PPAR agonists In light of the encouraging ndings obtained from clinical trials employing PPAR agonists, recent attention has begun to focus on compounds that are capable of targeting more than one PPAR isotype. Currently, these include PPAR/, PPAR/ and PPAR/ dual agonists, together with PPAR// pan agonists. PPAR/ dual agonists, such as tesaglitazar and muraglitazar were created in order to elicit synergistic anti-diabetic and cardioprotective effects (Chaput et al., 2000). Tesaglitazar has been demonstrated to reduce the development of atherosclerosis in an experimental mouse model (Chira et al., 2007) and to improve atherogenic dyslipidaemia in non-diabetic patients with insulin resistance (Schuster et al., 2008). Furthermore, a newly developed PPAR/ dual agonist has been found to not only improve insulin sensitivity, but also to prevent LV dysfunction in mice with combined leptin and LDL receptor deciency (Verreth et al., 2006). Dual activation of both PPAR and PPAR also appeared to reduce the side effects associated with PPAR activation alone. In this situation, increases in body weight and adipogenesis commonly encountered upon PPAR treatment are counteracted by PPAR-induced decreases in food intake and fat deposition (Etgen et al., 2002; Carmona et al., 2005). Despite these promising observations, tesaglitazar and muraglitazar have been discontinued in Phase III clinical trials due to concerns relating to adverse effects on renal function (Conlon, 2006) and the incidence of cardiovascular events (Nissen et al., 2005), respectively. Current research in this area is targeted towards developing a more specic PPAR/ agonist that is able to activate both receptors at therapeutic concentrations. Novel PPAR/ and PPAR/ dual agonists are currently under development and it is hoped that they will prove to be highly selective and benecial in the treatment of CVD in both the absence or presence of diabetes. Results with pan PPAR// agonists have been more encouraging, with bezabrate, the only currently marketed pan agonist, shown to improve insulin sensitivity, prevent myocardial ischaemic injury and slow the development of coronary artery disease. Other pan agonists have also been demonstrated to have benecial cardiovascular effects and are currently the subject of Phase I and II clinical trials (Balakumar et al., 2007).

3. Conclusions Since the discovery of nuclear PPARs in the early 1990s, the subsequent development of PPAR agonists and gene-modied animals has highlighted the involvement of these receptors in numerous biological pathways. PPARs are known to play an important role in the cardiovascular system and have been implicated in several CVDs. However, the complexity of PPAR activation, in combination with their diverse tissue distribution and lack of specicity of currently available PPAR agonists makes therapeutic modication of PPAR pathways a challenging goal. Further research aimed at the development of more effective agonists, together with pan agonists and SPPARM compounds will address some of the issues currently surrounding the potential use of PPAR activators in the treatment of CVD. However, a detailed understanding of the role of PPARs in the cardiovascular system is required in order to delineate the precise mechanisms by which PPARs may modify cellular CVD processes and enable identication of effective therapeutic targets. Acknowledgment The author's work is supported by the Medical Research Council. References
Aasum, E., Hafstad, A. D., Severson, D. L., & Larsen, T. S. (2003). Age-dependent changes in metabolism, contractile function, and ischemic sensitivity in hearts from db/db mice. Diabetes 52, 434441. Abate, N. (2000). Obesity and cardiovascular disease. Pathogenetic role of the metabolic syndrome and therapeutic implications. J Diabetes Complications 14, 154174. Achmad, T. H., & Rao, G. S. (1992). Chemotaxis of human blood monocytes toward endothelin-1 and the inuence of calcium channel blockers. Biochem Biophys Res Commun 189, 9941000. Adams, M., Reginato, M. J., Shao, D., Lazar, M. A., & Chatterjee, V. K. (1997). Transcriptional activation by peroxisome proliferator-activated receptor gamma is inhibited by phosphorylation at a consensus mitogen-activated protein kinase site. J Biol Chem 272, 51285132. Aggeli, I. K., Gaitanaki, C., & Beis, I. (2006). Involvement of JNKs and p38-MAPK/MSK1 pathways in H2O2-induced upregulation of heme oxygenase-1 mRNA in H9c2 cells. Cell Signal 18, 18011812. Akiyama, T. E., Sakai, S., Lambert, G., Nicol, C. J., Matsusue, K., Pimprale, S., et al. (2002). Conditional disruption of the peroxisome proliferator-activated receptor gamma gene in mice results in lowered expression of ABCA1, ABCG1, and apoE in macrophages and reduced cholesterol efux. Mol Cell Biol 22, 26072619. Arakawa, K., Ishihara, T., Aoto, M., Inamasu, M., Kitamura, K., & Saito, A. (2004). An antidiabetic thiazolidinedione induces eccentric cardiac hypertrophy by cardiac volume overload in rats. Clin Exp Pharmacol Physiol 31, 813. Asakawa, M., Takano, H., Nagai, T., Uozumi, H., Hasegawa, H., Kubota, N., et al. (2002). Peroxisome proliferator-activated receptor gamma plays a critical role in inhibition of cardiac hypertrophy in vitro and in vivo. Circulation 105, 12401246. Babaev, V. R., Yancey, P. G., Ryzhov, S. V., Kon, V., Breyer, M. D., Magnuson, M. A., et al. (2005). Conditional knockout of macrophage PPARgamma increases atherosclerosis in C57BL/6 and low-density lipoprotein receptor-decient mice. Arterioscler Thromb Vasc Biol 25, 16471653. Balakumar, P., Rose, M., Ganti, S. S., Krishan, P., & Singh, M. (2007). PPAR dual agonists: Are they opening Pandora's Box? Pharmacol Res 56, 9198. Barger, P. M., Brandt, J. M., Leone, T. C., Weinheimer, C. J., & Kelly, D. P. (2000). Deactivation of peroxisome proliferator-activated receptor-alpha during cardiac hypertrophic growth. J Clin Invest 105, 17231730. Barger, P. M., & Kelly, D. P. (2000). PPAR signaling in the control of cardiac energy metabolism. Trends Cardiovasc Med 10, 238245. Barger, P. M., Browning, A. C., Garner, A. N., & Kelly, D. P. (2001). p38 mitogen-activated protein kinase activates peroxisome proliferator-activated receptor alpha: A potential role in the cardiac metabolic stress response. J Biol Chem 276, 4449544501. Bensinger, S. J., & Tontonoz, P. (2008). Integration of metabolism and inammation by lipid-activated nuclear receptors. Nature 454, 470477. Berger, J., Leibowitz, M. D., Doebber, T. W., Elbrecht, A., Zhang, B., Zhou, G., et al. (1999). Novel peroxisome proliferator-activated receptor (PPAR) gamma and PPARdelta ligands produce distinct biological effects. J Biol Chem 274, 67186725. Berger, J., & Moller, D. E. (2002). The mechanisms of action of PPARs. Annu Rev Med 53, 409435. Bishop, S. P., & Altschuld, R. A. (1970). Increased glycolytic metabolism in cardiac hypertrophy and congestive failure. Am J Physiol 218, 153159. Blumberg, B., & Evans, R. M. (1998). Orphan nuclear receptorsNew ligands and new possibilities. Genes Dev 12, 31493155. Bouhlel, M. A., Derudas, B., Rigamonti, E., Dievart, R., Brozek, J., Haulon, S., et al. (2007). PPARgamma activation primes human monocytes into alternative M2 macrophages with anti-inammatory properties. Cell Metab 6, 137143.

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263 Braissant, O., Foufelle, F., Scotto, C., Dauca, M., & Wahli, W. (1996). Differential expression of peroxisome proliferator-activated receptors (PPARs): Tissue distribution of PPARalpha, -beta, and -gamma in the adult rat. Endocrinology 137, 354366. Brandt, J. M., Djouadi, F., & Kelly, D. P. (1998). Fatty acids activate transcription of the muscle carnitine palmitoyltransferase I gene in cardiac myocytes via the peroxisome proliferator-activated receptor alpha. J Biol Chem 273, 2378623792. Brown, M. S., & Goldstein, J. L. (1983). Lipoprotein metabolism in the macrophage: Implications for cholesterol deposition in atherosclerosis. Annu Rev Biochem 52, 223261. Brown, M. S., & Goldstein, J. L. (1990). Atherosclerosis. Scavenging for receptors. Nature 343, 508509. Bruemmer, D., Blaschke, F., & Law, R. E. (2005). New targets for PPARgamma in the vessel wall: Implications for restenosis. Int J Obes (Lond) 29(Suppl 1), S26S30. Bulhak, A. A., Sjoquist, P. O., Xu, C. B., Edvinsson, L., & Pernow, J. (2006). Protection against myocardial ischaemia/reperfusion injury by PPAR-alpha activation is related to production of nitric oxide and endothelin-1. Basic Res Cardiol 101, 244252. Caglayan, E., Stauber, B., Collins, A. R., Lyon, C. J., Yin, F., Liu, J., et al. (2008). Differential roles of cardiomyocyte and macrophage peroxisome proliferator-activated receptor gamma in cardiac brosis. Diabetes 57, 24702479. Calnek, D. S., Mazzella, L., Roser, S., Roman, J., & Hart, C. M. (2003). Peroxisome proliferator-activated receptor gamma ligands increase release of nitric oxide from endothelial cells. Arterioscler Thromb Vasc Biol 23, 5257. Camp, H. S., & Tafuri, S. R. (1997). Regulation of peroxisome proliferator-activated receptor gamma activity by mitogen-activated protein kinase. J Biol Chem 272, 1081110816. Carmona, M. C., Louche, K., Nibbelink, M., Prunet, B., Bross, A., Desbazeille, M., et al. (2005). Fenobrate prevents Rosiglitazone-induced body weight gain in ob/ob mice. Int J Obes (Lond) 29, 864871. Chaput, E., Saladin, R., Silvestre, M., & Edgar, A. D. (2000). Fenobrate and rosiglitazone lower serum triglycerides with opposing effects on body weight. Biochem Biophys Res Commun 271, 445450. Chen, J. D., & Evans, R. M. (1995). A transcriptional co-repressor that interacts with nuclear hormone receptors. Nature 377, 454457. Cheng, L., Ding, G., Qin, Q., Xiao, Y., Woods, D., Chen, Y. E., et al. (2004a). Peroxisome proliferator-activated receptor delta activates fatty acid oxidation in cultured neonatal and adult cardiomyocytes. Biochem Biophys Res Commun 313, 277286. Cheng, L., Ding, G., Qin, Q., Huang, Y., Lewis, W., He, N., et al. (2004b). Cardiomyocyterestricted peroxisome proliferator-activated receptor-delta deletion perturbs myocardial fatty acid oxidation and leads to cardiomyopathy. Nat Med 10, 12451250. Chevalier, S., & Roberts, R. A. (1998). Perturbation of rodent hepatocyte growth control by nongenotoxic hepatocarcinogens: Mechanisms and lack of relevance for human health (review). Oncol Rep 5, 13191327. Chinetti-Gbaguidi, G., Fruchart, J. C., & Staels, B. (2005a). Role of the PPAR family of nuclear receptors in the regulation of metabolic and cardiovascular homeostasis: New approaches to therapy. Curr Opin Pharmacol 5, 177183. Chinetti-Gbaguidi, G., Rigamonti, E., Helin, L., Mutka, A. L., Lepore, M., Fruchart, J. C., et al. (2005b). Peroxisome proliferator-activated receptor alpha controls cellular cholesterol trafcking in macrophages. J Lipid Res 46, 27172725. Chinetti, G., Griglio, S., Antonucci, M., Torra, I. P., Delerive, P., Majd, Z., et al. (1998). Activation of proliferator-activated receptors alpha and gamma induces apoptosis of human monocyte-derived macrophages. J Biol Chem 273, 2557325580. Chinetti, G., Lestavel, S., Bocher, V., Remaley, A. T., Neve, B., Torra, I. P., et al. (2001). PPARalpha and PPAR-gamma activators induce cholesterol removal from human macrophage foam cells through stimulation of the ABCA1 pathway. Nat Med 7, 5358. Chira, E. C., McMillen, T. S., Wang, S., Haw, A., III, O, Brien , K. D., Wight, T. N., et al. (2007). Tesaglitazar, a dual peroxisome proliferator-activated receptor alpha/gamma agonist, reduces atherosclerosis in female low density lipoprotein receptor decient mice. Atherosclerosis 195, 100109. Christe, M. E., & Rodgers, R. L. (1994). Altered glucose and fatty acid oxidation in hearts of the spontaneously hypertensive rat. J Mol Cell Cardiol 26, 13711375. Conlon, D. (2006). Goodbye glitazars? Br J Diabetes Vasc Dis 6, 135137. Delerive, P., Martin-Nizard, F., Chinetti, G., Trottein, F., Fruchart, J. C., Najib, J., et al. (1999a). Peroxisome proliferator-activated receptor activators inhibit thrombininduced endothelin-1 production in human vascular endothelial cells by inhibiting the activator protein-1 signaling pathway. Circ Res 85, 394402. Delerive, P., De, B. K., Besnard, S., Vanden, B. W., Peters, J. M., Gonzalez, F. J., et al. (1999b). Peroxisome proliferator-activated receptor alpha negatively regulates the vascular inammatory gene response by negative cross-talk with transcription factors NF-kappaB and AP-1. J Biol Chem 274, 3204832054. Devchand, P. R., Keller, H., Peters, J. M., Vazquez, M., Gonzalez, F. J., & Wahli, W. (1996). The PPARalpha-leukotriene B4 pathway to inammation control. Nature 384, 3943. Dewald, O., Sharma, S., Adrogue, J., Salazar, R., Duerr, G. D., Crapo, J. D., et al. (2005). Downregulation of peroxisome proliferator-activated receptor-alpha gene expression in a mouse model of ischemic cardiomyopathy is dependent on reactive oxygen species and prevents lipotoxicity. Circulation 112, 407415. Diep, Q. N., & Schiffrin, E. L. (2001). Increased expression of peroxisome proliferatoractivated receptor-alpha and -gamma in blood vessels of spontaneously hypertensive rats. Hypertension 38, 249254. Diep, Q. N., Amiri, F., Touyz, R. M., Cohn, J. S., Endemann, D., Neves, M. F., et al. (2002a). PPARalpha activator effects on Ang II-induced vascular oxidative stress and inammation. Hypertension 40, 866871. Diep, Q. N., Benkirane, K., Amiri, F., Cohn, J. S., Endemann, D., & Schiffrin, E. L. (2004). PPAR alpha activator fenobrate inhibits myocardial inammation and brosis in angiotensin II-infused rats. J Mol Cell Cardiol 36, 295304.

259

Diep, Q. N., El, M. M., Cohn, J. S., Endemann, D., Amiri, F., Virdis, A., et al. (2002b). Structure, endothelial function, cell growth, and inammation in blood vessels of angiotensin II-infused rats: role of peroxisome proliferator-activated receptorgamma. Circulation 105, 22962302. Diep, Q. N., Touyz, R. M., & Schiffrin, E. L. (2000). Docosahexaenoic acid, a peroxisome proliferator-activated receptor-alpha ligand, induces apoptosis in vascular smooth muscle cells by stimulation of p38 mitogen-activated protein kinase. Hypertension 36, 851855. Ding, N. Z., Ma, X. H., Diao, H. L., Xu, L. B., & Yang, Z. M. (2003). Differential expression of peroxisome proliferator-activated receptor delta at implantation sites and in decidual cells of rat uterus. Reproduction 125, 817825. Djouadi, F., Weinheimer, C. J., Saftz, J. E., Pitchford, C., Bastin, J., Gonzalez, F. J., et al. (1998). A gender-related defect in lipid metabolism and glucose homeostasis in peroxisome proliferator-activated receptor alpha-decient mice. J Clin Invest 102, 10831091. Dormandy, J. A., Charbonnel, B., Eckland, D. J., Erdmann, E., Massi-Benedetti, M., Moules, I. K., et al. (2005). Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial In macroVascular Events): A randomised controlled trial. Lancet 366, 12791289. Dragomir, E., Tircol, M., Manduteanu, I., Voinea, M., & Simionescu, M. (2006). Aspirin and PPAR-alpha activators inhibit monocyte chemoattractant protein-1 expression induced by high glucose concentration in human endothelial cells. Vascul Pharmacol 44, 440449. Dreyer, C., Krey, G., Keller, H., Givel, F., Helftenbein, G., & Wahli, W. (1992). Control of the peroxisomal beta-oxidation pathway by a novel family of nuclear hormone receptors. Cell 68, 879887. Duan, S. Z., Ivashchenko, C. Y., Russell, M. W., Milstone, D. S., & Mortensen, R. M. (2005). Cardiomyocyte-specic knockout and agonist of peroxisome proliferator-activated receptor-gamma both induce cardiac hypertrophy in mice. Circ Res 97, 372379. Duan, S. Z., Ivashchenko, C. Y., Whitesall, S. E., D, Alecy , L. G., Duquaine, D. C., Brosius, F. C., III, et al. (2007). Hypotension, lipodystrophy, and insulin resistance in generalized PPARgamma-decient mice rescued from embryonic lethality. J Clin Invest 117, 812822. Duan, S. Z., Usher, M. G., & Mortensen, R. M. (2008). Peroxisome proliferator-activated receptor-gamma-mediated effects in the vasculature. Circ Res 102, 283294. Duhaney, T. A., Cui, L., Rude, M. K., Lebrasseur, N. K., Ngoy, S., De Silva, D. S., et al. (2007). Peroxisome proliferator-activated receptor alpha-independent actions of fenobrate exacerbates left ventricular dilation and brosis in chronic pressure overload. Hypertension 49, 10841094. Edgley, A. J., Thalen, P. G., Dahllof, B., Lanne, B., Ljung, B., & Oakes, N. D. (2006). PPARgamma agonist induced cardiac enlargement is associated with reduced fatty acid and increased glucose utilization in myocardium of Wistar rats. Eur J Pharmacol 538, 195206. Egan, B. M., Greene, E. L., & Goodfriend, T. L. (2001). Nonesteried fatty acids in blood pressure control and cardiovascular complications. Curr Hypertens Rep 3, 107116. Erdmann, E., & Wilcox, R. G. (2008). Weighing up the cardiovascular benets of thiazolidinedione therapy: The impact of increased risk of heart failure. Eur Heart J 29, 1220. Escher, P., & Wahli, W. (2000). Peroxisome proliferator-activated receptors: Insight into multiple cellular functions. Mutat Res 448, 121138. Etgen, G. J., Oldham, B. A., Johnson, W. T., Broderick, C. L., Montrose, C. R., Brozinick, J. T., et al. (2002). A tailored therapy for the metabolic syndrome: The dual peroxisome proliferator-activated receptor-alpha/gamma agonist LY465608 ameliorates insulin resistance and diabetic hyperglycemia while improving cardiovascular risk factors in preclinical models. Diabetes 51, 10831087. Faggiotto, A., Ross, R., & Harker, L. (1984). Studies of hypercholesterolemia in the nonhuman primate. I. Changes that lead to fatty streak formation. Arteriosclerosis 4, 323340. Fajas, L., Auboeuf, D., Raspe, E., Schoonjans, K., Lefebvre, A. M., Saladin, R., et al. (1997). The organization, promoter analysis, and expression of the human PPARgamma gene. J Biol Chem 272, 1877918789. Finck, B. N., Lehman, J. J., Leone, T. C., Welch, M. J., Bennett, M. J., Kovacs, A., et al. (2002). The cardiac phenotype induced by PPARalpha overexpression mimics that caused by diabetes mellitus. J Clin Invest 109, 121130. Forman, B. M., Chen, J., & Evans, R. M. (1997). Hypolipidemic drugs, polyunsaturated fatty acids, and eicosanoids are ligands for peroxisome proliferator-activated receptors alpha and delta. Proc Natl Acad Sci USA 94, 43124317. Forman, B. M., Tontonoz, P., Chen, J., Brun, R. P., Spiegelman, B. M., & Evans, R. M. (1995). 15-Deoxy-delta 12, 14-prostaglandin J2 is a ligand for the adipocyte determination factor PPAR gamma. Cell 83, 803812. Francis, G. S., & Young, J. B. (2001). The looming polypharmacy crisis in the management of patients with heart failure. Potential solutions. Cardiol Clin 19, 541545. Frangogiannis, N. G., Smith, C. W., & Entman, M. L. (2002). The inammatory response in myocardial infarction. Cardiovasc Res 53, 3147. Frey, N., & Olson, E. N. (2002). Modulating cardiac hypertrophy by manipulating myocardial lipid metabolism? Circulation 105, 11521154. Frey, N., & Olson, E. N. (2003). Cardiac hypertrophy: The good, the bad, and the ugly. Annu Rev Physiol 65, 4579. Frick, M. H., Elo, O., Haapa, K., Heinonen, O. P., Heinsalmi, P., Helo, P., et al. (1987). Helsinki heart study: Primary-prevention trial with gembrozil in middle-aged men with dyslipidemia. Safety of treatment, changes in risk factors, and incidence of coronary heart disease. N Engl J Med 317, 12371245. Fruchart, J. C. (2007). Novel peroxisome proliferator activated receptor-alpha agonists. Am J Cardiol 100, n41n46.

260

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263 Iglarz, M., Touyz, R. M., Viel, E. C., Paradis, P., Amiri, F., Diep, Q. N., et al. (2003). Peroxisome proliferator-activated receptor-alpha and receptor-gamma activators prevent cardiac brosis in mineralocorticoid-dependent hypertension. Hypertension 42, 737743. IJpenberg, A., Jeannin, E., Wahli, W., & Desvergne, B. (1997). Polarity and specic sequence requirements of peroxisome proliferator-activated receptor (PPAR)/ retinoid X receptor heterodimer binding to DNA. A functional analysis of the malic enzyme gene PPAR response element. J Biol Chem 272, 2010820117. Inoue, I., Shino, K., Noji, S., Awata, T., & Katayama, S. (1998). Expression of peroxisome proliferator-activated receptor alpha (PPAR alpha) in primary cultures of human vascular endothelial cells. Biochem Biophys Res Commun 246, 370374. Irukayama-Tomobe, Y., Miyauchi, T., Sakai, S., Kasuya, Y., Ogata, T., Takanashi, M., et al. (2004). Endothelin-1-induced cardiac hypertrophy is inhibited by activation of peroxisome proliferator-activated receptor-alpha partly via blockade of c-Jun NH2terminal kinase pathway. Circulation 109, 904910. Ishibashi, M., Egashira, K., Hiasa, K., Inoue, S., Ni, W., Zhao, Q., et al. (2002). Antiinammatory and antiarteriosclerotic effects of pioglitazone. Hypertension 40, 687693. Issemann, I., & Green, S. (1990). Activation of a member of the steroid hormone receptor superfamily by peroxisome proliferators. Nature 347, 645650. Ito, H., Nakano, A., Kinoshita, M., & Matsumori, A. (2003). Pioglitazone, a peroxisome proliferator-activated receptor-gamma agonist, attenuates myocardial ischemia/ reperfusion injury in a rat model. Lab Invest 83, 17151721. Jackson, L., Wahli, W., Michalik, L., Watson, S. A., Morris, T., Anderton, K., et al. (2003). Potential role for peroxisome proliferator activated receptor (PPAR) in preventing colon cancer. Gut 52, 13171322. Jamshidi, Y., Montgomery, H. E., Hense, H. W., Myerson, S. G., Torra, I. P., Staels, B., et al. (2002). Peroxisome proliferator-activated receptor alpha gene regulates left ventricular growth in response to exercise and hypertension. Circulation 105, 950955. Jiang, C., Ting, A. T., & Seed, B. (1998). PPAR-gamma agonists inhibit production of monocyte inammatory cytokines. Nature 391, 8286. Johnson, T. E., Holloway, M. K., Vogel, R., Rutledge, S. J., Perkins, J. J., Rodan, G. A., et al. (1997). Structural requirements and cell-type specicity for ligand activation of peroxisome proliferator-activated receptors. J Steroid Biochem Mol Biol 63, 18. Jones, G. T., van Rij, A. M., Solomon, C., Thomson, I. A., & Packer, S. G. (1996). Endothelin1 is increased overlying atherosclerotic plaques in human arteries. Atherosclerosis 124, 2535. Juge-Aubry, C. E., Hammar, E., Siegrist-Kaiser, C., Pernin, A., Takeshita, A., Chin, W. W., et al. (1999). Regulation of the transcriptional activity of the peroxisome proliferatoractivated receptor alpha by phosphorylation of a ligand-independent trans-activating domain. J Biol Chem 274, 1050510510. Kang, K., Reilly, S. M., Karabacak, V., Gangl, M. R., Fitzgerald, K., Hatano, B., et al. (2008). Adipocyte-derived Th2 cytokines and myeloid PPARdelta regulate macrophage polarization and insulin sensitivity. Cell Metab 7, 485495. Kannel, W. B. (1997). Hazards, risks, and threats of heart disease from the early stages to symptomatic coronary heart disease and cardiac failure. Cardiovasc Drugs Ther 11 (Suppl 1), 199212. Kaplan, J., Cook, J. A., O, Connor , M., & Zingarelli, B. (2007). Peroxisome proliferatoractivated receptor gamma is required for the inhibitory effect of ciglitazone but not 15-deoxy-Delta 12,14-prostaglandin J2 on the NFkappaB pathway in human endothelial cells. Shock 28, 722726. Keech, A., Simes, R. J., Barter, P., Best, J., Scott, R., Taskinen, M. R., et al. (2005). Effects of longterm fenobrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): Randomised controlled trial. Lancet 366, 18491861. Kelly, D. P., & Strauss, A. W. (1994). Inherited cardiomyopathies. N Engl J Med 330, 913919. Khandoudi, N., Delerive, P., Berrebi-Bertrand, I., Buckingham, R. E., Staels, B., & Bril, A. (2002). Rosiglitazone, a peroxisome proliferator-activated receptor-gamma, inhibits the Jun NH(2)-terminal kinase/activating protein 1 pathway and protects the heart from ischemia/reperfusion injury. Diabetes 51, 15071514. Kliewer, S. A., Forman, B. M., Blumberg, B., Ong, E. S., Borgmeyer, U., Mangelsdorf, D. J., et al. (1994). Differential expression and activation of a family of murine peroxisome proliferator-activated receptors. Proc Natl Acad Sci USA 91, 73557359. Kliewer, S. A., Lenhard, J. M., Willson, T. M., Patel, I., Morris, D. C., & Lehmann, J. M. (1995). A prostaglandin J2 metabolite binds peroxisome proliferator-activated receptor gamma and promotes adipocyte differentiation. Cell 83, 813819. Kliewer, S. A., Sundseth, S. S., Jones, S. A., Brown, P. J., Wisely, G. B., Koble, C. S., et al. (1997). Fatty acids and eicosanoids regulate gene expression through direct interactions with peroxisome proliferator-activated receptors alpha and gamma. Proc Natl Acad Sci USA 94, 43184323. Kliewer, S. A., Umesono, K., Noonan, D. J., Heyman, R. A., & Evans, R. M. (1992). Convergence of 9-cis retinoic acid and peroxisome proliferator signalling pathways through heterodimer formation of their receptors. Nature 358, 771774. Kliewer, S. A., Xu, H. E., Lambert, M. H., & Willson, T. M. (2001). Peroxisome proliferatoractivated receptors: from genes to physiology. Recent Prog Horm Res 56, 239263. Knopp, R. H. (1999). Drug treatment of lipid disorders. N Engl J Med 341, 498511. Kobori, H., Ozawa, Y., Suzaki, Y., & Nishiyama, A. (2005). Enhanced intrarenal angiotensinogen contributes to early renal injury in spontaneously hypertensive rats. J Am Soc Nephrol 16, 20732080. Kota, B. P., Huang, T. H., & Roufogalis, B. D. (2005). An overview on biological mechanisms of PPARs. Pharmacol Res 51, 8594. Kubota, T., Koshizuka, K., Williamson, E. A., Asou, H., Said, J. W., Holden, S., et al. (1998). Ligand for peroxisome proliferator-activated receptor gamma (troglitazone) has potent antitumor effect against human prostate cancer both in vitro and in vivo. Cancer Res 58, 33443352. Law, R. E., Goetze, S., Xi, X. P., Jackson, S., Kawano, Y., Demer, L., et al. (2000). Expression and function of PPARgamma in rat and human vascular smooth muscle cells. Circulation 101, 13111318.

Gbaguidi, F. G., Chinetti, G., Milosavljevic, D., Teissier, E., Chapman, J., Olivecrona, G., et al. (2002). Peroxisome proliferator-activated receptor (PPAR) agonists decrease lipoprotein lipase secretion and glycated LDL uptake by human macrophages. FEBS Lett 512, 8590. Geng, D. F., Wu, W., Jin, D. M., Wang, J. F., & Wu, Y. M. (2006). Effect of peroxisome proliferator-activated receptor gamma ligand. Rosiglitazone on left ventricular remodeling in rats with myocardial infarction. Int J Cardiol 113, 8691. Gervois, P., Torra, I. P., Chinetti, G., Grotzinger, T., Dubois, G., Fruchart, J. C., et al. (1999). A truncated human peroxisome proliferator-activated receptor alpha splice variant with dominant negative activity. Mol Endocrinol 13, 15351549. Giguere, V. (1999). Orphan nuclear receptors: from gene to function. Endocr Rev 20, 689725. Gilde, A. J., & Van Bilsen, M. (2003). Peroxisome proliferator-activated receptors (PPARS): Regulators of gene expression in heart and skeletal muscle. Acta Physiol Scand 178, 425434. Gilde, A. J., van der Lee, K. A., Willemsen, P. H., Chinetti, G., van der Leij, F. R., van, d. V., et al. (2003). Peroxisome proliferator-activated receptor (PPAR) alpha and PPARbeta/delta, but not PPARgamma, modulate the expression of genes involved in cardiac lipid metabolism. Circ Res 92, 518524. Goldstein, J. L., Ho, Y. K., Basu, S. K., & Brown, M. S. (1979). Binding site on macrophages that mediates uptake and degradation of acetylated low density lipoprotein, producing massive cholesterol deposition. Proc Natl Acad Sci USA 76, 333337. Gonon, A. T., Bulhak, A., Labruto, F., Sjoquist, P. O., & Pernow, J. (2007). Cardioprotection mediated by rosiglitazone, a peroxisome proliferator-activated receptor gamma ligand, in relation to nitric oxide. Basic Res Cardiol 102, 8089. Gonzalez, F. J., Peters, J. M., & Cattley, R. C. (1998). Mechanism of action of the nongenotoxic peroxisome proliferators: Role of the peroxisome proliferatoractivator receptor alpha. J Natl Cancer Inst 90, 17021709. Gottlicher, M., Widmark, E., Li, Q., & Gustafsson, J. A. (1992). Fatty acids activate a chimera of the clobric acid-activated receptor and the glucocorticoid receptor. Proc Natl Acad Sci USA 89, 46534657. Goya, K., Sumitani, S., Xu, X., Kitamura, T., Yamamoto, H., Kurebayashi, S., et al. (2004). Peroxisome proliferator-activated receptor alpha agonists increase nitric oxide synthase expression in vascular endothelial cells. Arterioscler Thromb Vasc Biol 24, 658663. Gradman, A. H., & Alfayoumi, F. (2006). From left ventricular hypertrophy to congestive heart failure: management of hypertensive heart disease. Prog Cardiovasc Dis 48, 326341. Graham, T. L., Mookherjee, C., Suckling, K. E., Palmer, C. N., & Patel, L. (2005). The PPARdelta agonist GW0742X reduces atherosclerosis in LDLR(/) mice. Atherosclerosis 181, 2937. Greene, M. E., Blumberg, B., McBride, O. W., Yi, H. F., Kronquist, K., Kwan, K., et al. (1995). Isolation of the human peroxisome proliferator activated receptor gamma cDNA: Expression in hematopoietic cells and chromosomal mapping. Gene Expr 4, 281299. Grinsell, J. W., Lardinois, C. K., Swislocki, A., Gonzalez, R., Sare, J. S., Michaels, J. R., et al. (2000). Pioglitazone attenuates basal and postprandial insulin concentrations and blood pressure in the spontaneously hypertensive rat. Am J Hypertens 13, 370375. Grundy, S. M. (2004). Obesity, metabolic syndrome, and cardiovascular disease. J Clin Endocrinol Metab 89, 25952600. Guellich, A., Damy, T., Lecarpentier, Y., Conti, M., Claes, V., Samuel, J. L., et al. (2007). Role of oxidative stress in cardiac dysfunction of PPARalpha/ mice. Am J Physiol Heart Circ Physiol 293, H93H102. Gupta, R. A., Tan, J., Krause, W. F., Geraci, M. W., Willson, T. M., Dey, S. K., et al. (2000). Prostacyclin-mediated activation of peroxisome proliferator-activated receptor delta in colorectal cancer. Proc Natl Acad Sci USA 97, 1327513280. Hamano, T., Kobayashi, K., Sakairi, T., Hayashi, M., & Mutai, M. (2001). Peroxisome proliferator-activated receptor alpha (PPAR alpha) agonist, Wy 14,643, increased transcription of myosin light chain-2 in cardiomyocytes. J Toxicol Sci 26, 275284. Han, C., Demetris, A. J., Michalopoulos, G., Shelhamer, J. H., & Wu, T. (2002). 85-kDa cPLA(2) plays a critical role in PPAR-mediated gene transcription in human hepatoma cells. Am J Physiol Gastrointest Liver Physiol 282, G586G597. Han, J., Hajjar, D. P., Tauras, J. M., Feng, J., Gotto, A. M., Jr., & Nicholson, A. C. (2000). Transforming growth factor-beta1 (TGF-beta1) and TGF-beta2 decrease expression of CD36, the type B scavenger receptor, through mitogen-activated protein kinase phosphorylation of peroxisome proliferator-activated receptor-gamma. J Biol Chem 275, 12411246. Haraguchi, G., Kobayashi, Y., Brown, M. L., Tanaka, A., Isobe, M., Gianturco, S. H., et al. (2003). PPAR(alpha) and PPAR(gamma) activators suppress the monocytemacrophage apoB-48 receptor. J Lipid Res 44, 12241231. Harman, F. S., Nicol, C. J., Marin, H. E., Ward, J. M., Gonzalez, F. J., & Peters, J. M. (2004). Peroxisome proliferator-activated receptor-delta attenuates colon carcinogenesis. Nat Med 10, 481483. Healey, J. S., & Connolly, S. J. (2003). Atrial brillation: Hypertension as a causative agent, risk factor for complications, and potential therapeutic target. Am J Cardiol 91, 9G14G. Henderson, B. C., Sen, U., Reynolds, C., Moshal, K. S., Ovechkin, A., Tyagi, N., et al. (2007). Reversal of systemic hypertension-associated cardiac remodeling in chronic pressure overload myocardium by ciglitazone. Int J Biol Sci 3, 385392. Horlein, A. J., Naar, A. M., Heinzel, T., Torchia, J., Gloss, B., Kurokawa, R., et al. (1995). Ligand-independent repression by the thyroid hormone receptor mediated by a nuclear receptor co-repressor. Nature 377, 397404. Ichihara, S., Obata, K., Yamada, Y., Nagata, K., Noda, A., Ichihara, G., et al. (2006). Attenuation of cardiac dysfunction by a PPAR-alpha agonist is associated with downregulation of redox-regulated transcription factors. J Mol Cell Cardiol 41, 318329.

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263 Law, R. E., Meehan, W. P., Xi, X. P., Graf, K., Wuthrich, D. A., Coats, W., et al. (1996). Troglitazone inhibits vascular smooth muscle cell growth and intimal hyperplasia. J Clin Invest 98, 18971905. Lee, T. M., & Chou, T. F. (2003). Troglitazone administration limits infarct size by reduced phosphorylation of canine myocardial connexin43 proteins. Am J Physiol Heart CircPhysiol 285, H1650H1659. Lee, C. H., Kang, K., Mehl, I. R., Nofsinger, R., Alaynick, W. A., Chong, L. W., et al. (2006). Peroxisome proliferator-activated receptor delta promotes very low-density lipoprotein-derived fatty acid catabolism in the macrophage. Proc Natl Acad Sci USA 103, 24342439. Lee, H., Shi, W., Tontonoz, P., Wang, S., Subbanagounder, G., Hedrick, C. C., et al. (2000). Role for peroxisome proliferator-activated receptor alpha in oxidized phospholipidinduced synthesis of monocyte chemotactic protein-1 and interleukin-8 by endothelial cells. Circ Res 87, 516521. Lehmann, J. M., Lenhard, J. M., Oliver, B. B., Ringold, G. M., & Kliewer, S. A. (1997). Peroxisome proliferator-activated receptors alpha and gamma are activated by indomethacin and other non-steroidal anti-inammatory drugs. J Biol Chem 272, 34063410. Lemberger, T., Saladin, R., Vazquez, M., Assimacopoulos, F., Staels, B., Desvergne, B., et al. (1996). Expression of the peroxisome proliferator-activated receptor alpha gene is stimulated by stress and follows a diurnal rhythm. J Biol Chem 271, 17641769. Li, A. C., Binder, C. J., Gutierrez, A., Brown, K. K., Plotkin, C. R., Pattison, J. W., et al. (2004). Differential inhibition of macrophage foamcell formation and atherosclerosis in mice by PPARalpha, beta/delta, and gamma. J Clin Invest 114, 15641576. Li, C., Browder, W., & Kao, R. L. (1999). Early activation of transcription factor NF-kappaB during ischemia in perfused rat heart. Am J Physiol 276, H543H552. Li, A. C., Brown, K. K., Silvestre, M. J., Willson, T. M., Palinski, W., & Glass, C. K. (2000). Peroxisome proliferator-activated receptor gamma ligands inhibit development of atherosclerosis in LDL receptor-decient mice. J Clin Invest 106, 523531. Li, C. B., Li, X. X., Chen, Y. G., Zhang, C., Zhang, M. X., Zhao, X. Q., et al. (2008). Effects and mechanisms of PPARalpha activator fenobrate on myocardial remodeling in hypertension. J Cell Mol Med. Li, R., Zheng, W., Pi, R., Gao, J., Zhang, H., Wang, P., et al. (2007). Activation of peroxisome proliferator-activated receptor-alpha prevents glycogen synthase 3beta phosphorylation and inhibits cardiac hypertrophy. FEBS Lett 581, 33113316. Liang, F., Wang, F., Zhang, S., & Gardner, D. G. (2003). Peroxisome proliferator activated receptor (PPAR)alpha agonists inhibit hypertrophy of neonatal rat cardiac myocytes. Endocrinology 144, 41874194. Libby, P., Geng, Y. J., Aikawa, M., Schoenbeck, U., Mach, F., Clinton, S. K., et al. (1996). Macrophages and atherosclerotic plaque stability. Curr Opin Lipidol 7, 330335. Lim, H., Gupta, R. A., Ma, W. G., Paria, B. C., Moller, D. E., Morrow, J. D., et al. (1999). Cyclooxygenase-2-derived prostacyclin mediates embryo implantation in the mouse via PPARdelta. Genes Dev 13, 15611574. Lin, J., Puigserver, P., Donovan, J., Tarr, P., & Spiegelman, B. M. (2002). Peroxisome proliferator-activated receptor gamma coactivator 1beta (PGC-1beta), a novel PGC-1-related transcription coactivator associated with host cell factor. J Biol Chem 277, 16451648. Lindberg, M., & Astrup, A. (2007). The role of glitazones in management of type 2 diabetes. A dream or a nightmare? Obes Rev 8, 381384. Liu, H. R., Tao, L., Gao, E., Lopez, B. L., Christopher, T. A., Willette, R. N., et al. (2004). Antiapoptotic effects of rosiglitazone in hypercholesterolemic rabbits subjected to myocardial ischemia and reperfusion. Cardiovasc Res 62, 135144. Lock, E. A., Mitchell, A. M., & Elcombe, C. R. (1989). Biochemical mechanisms of induction of hepatic peroxisome proliferation. Annu Rev Pharmacol Toxicol 29, 145163. Loichot, C., Jesel, L., Tesse, A., Tabernero, A., Schoonjans, K., Roul, G., et al. (2006). Deletion of peroxisome proliferator-activated receptor-alpha induces an alteration of cardiac functions. Am J Physiol Heart Circ Physiol 291, H161H166. Luptak, I., Balschi, J. A., Xing, Y., Leone, T. C., Kelly, D. P., & Tian, R. (2005). Decreased contractile and metabolic reserve in peroxisome proliferator-activated receptoralpha-null hearts can be rescued by increasing glucose transport and utilization. Circulation 112, 23392346. Lygate, C. A., Hulbert, K., Monfared, M., Cole, M. A., Clarke, K., & Neubauer, S. (2003). The PPARgamma-activator rosiglitazone does not alter remodeling but increases mortality in rats post-myocardial infarction. Cardiovasc Res 58, 632637. Majai, G., Sarang, Z., Csomos, K., Zahuczky, G., & Fesus, L. (2007). PPARgammadependent regulation of human macrophages in phagocytosis of apoptotic cells. Eur J Immunol 37, 13431354. Mangelsdorf, D. J., & Evans, R. M. (1995). The RXR heterodimers and orphan receptors. Cell 83, 841850. Marx, N., Mach, F., Sauty, A., Leung, J. H., Sara, M. N., Ransohoff, R. M., et al. (2000). Peroxisome proliferator-activated receptor-gamma activators inhibit IFN-gammainduced expression of the T cell-active CXC chemokines IP-10, Mig, and I-TAC in human endothelial cells. J Immunol 164, 65036508. Marx, N., Sukhova, G. K., Collins, T., Libby, P., & Plutzky, J. (1999). PPARalpha activators inhibit cytokine-induced vascular cell adhesion molecule-1 expression in human endothelial cells. Circulation 99, 31253131. Marx, N., Sukhova, G., Murphy, C., Libby, P., & Plutzky, J. (1998). Macrophages in human atheroma contain PPARgamma: Differentiation-dependent peroxisomal proliferator-activated receptor gamma(PPARgamma) expression and reduction of MMP-9 activity through PPARgamma activation in mononuclear phagocytes in vitro. Am J Pathol 153, 1723. Mazzone, T., Meyer, P. M., Feinstein, S. B., Davidson, M. H., Kondos, G. T., D, Agostino, R. B., Sr., et al. (2006). Effect of pioglitazone compared with glimepiride on carotid intimamedia thickness in type 2 diabetes: A randomized trial. JAMA 296, 25722581. McCarron, R. M., Wang, L., Stanimirovic, D. B., & Spatz, M. (1993). Endothelin induction of adhesion molecule expression on human brain microvascular endothelial cells. Neurosci Lett 156, 3134.

261

Michalik, L., Auwerx, J., Berger, J. P., Chatterjee, V. K., Glass, C. K., Gonzalez, F. J., et al. (2006). International Union of Pharmacology. LXI. Peroxisome proliferatoractivated receptors. Pharmacol Rev 58, 726741. Molavi, B., Chen, J., & Mehta, J. L. (2006). Cardioprotective effects of rosiglitazone are associated with selective overexpression of type 2 angiotensin receptors and inhibition of p42/44 MAPK. Am J Physiol Heart Circ Physiol 291, H687H693. Moller, D. E. (2000). Potential role of TNF-alpha in the pathogenesis of insulin resistance and type 2 diabetes. Trends Endocrinol Metab 11, 212217. Morgan, E. E., Rennison, J. H., Young, M. E., McElfresh, T. A., Kung, T. A., Tserng, K. Y., et al. (2006). Effects of chronic activation of peroxisome proliferator-activated receptoralpha or high-fat feeding in a rat infarct model of heart failure. Am J Physiol Heart Circ Physiol 290, H1899H1904. Mueller, E., Sarraf, P., Tontonoz, P., Evans, R. M., Martin, K. J., Zhang, M., et al. (1998). Terminal differentiation of human breast cancer through PPAR gamma. Mol Cell 1, 465470. Nagy, L., Tontonoz, P., Alvarez, J. G., Chen, H., & Evans, R. M. (1998). Oxidized LDL regulates macrophage gene expression through ligand activation of PPARgamma. Cell 93, 229240. Newaz, M., Blanton, A., Fidelis, P., & Oyekan, A. (2005). NAD(P)H oxidase/nitric oxide interactions in peroxisome proliferator activated receptor (PPAR)alpha-mediated cardiovascular effects. Mutat Res 579, 163171. Nissen, S. E., & Wolski, K. (2007). Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med 356, 24572471. Nissen, S. E., Wolski, K., & Topol, E. J. (2005). Effect of muraglitazar on death and major adverse cardiovascular events in patients with type 2 diabetes mellitus. JAMA 294, 25812586. Nolte, R. T., Wisely, G. B., Westin, S., Cobb, J. E., Lambert, M. H., Kurokawa, R., et al. (1998). Ligand binding and co-activator assembly of the peroxisome proliferatoractivated receptor-gamma. Nature 395, 137143. Odegaard, J. I., Ricardo-Gonzalez, R. R., Goforth, M. H., Morel, C. R., Subramanian, V., Mukundan, L., et al. (2007). Macrophage-specic PPARgamma controls alternative activation and improves insulin resistance. Nature 447, 11161120. Odegaard, J. I., Ricardo-Gonzalez, R. R., Red, E. A., Vats, D., Morel, C. R., Goforth, M. H., et al. (2008). Alternative M2 activation of Kupffer cells by PPARdelta ameliorates obesityinduced insulin resistance. Cell Metab 7, 496507. Ogata, T., Miyauchi, T., Sakai, S., Irukayama-Tomobe, Y., Goto, K., & Yamaguchi, I. (2002). Stimulation of peroxisome-proliferator-activated receptor alpha (PPAR alpha) attenuates cardiac brosis and endothelin-1 production in pressure-overloaded rat hearts. Clin Sci (Lond) 103(Suppl 48), 284S288S. Okuno, A., Tamemoto, H., Tobe, K., Ueki, K., Mori, Y., Iwamoto, K., et al. (1998). Troglitazone increases the number of small adipocytes without the change of white adipose tissue mass in obese Zucker rats. J Clin Invest 101, 13541361. Oliver, W. R., Jr., Shenk, J. L., Snaith, M. R., Russell, C. S., Plunket, K. D., Bodkin, N. L., et al. (2001). A selective peroxisome proliferator-activated receptor delta agonist promotes reverse cholesterol transport. Proc Natl Acad Sci USA 98, 53065311. Onai, Y., Suzuki, J., Kakuta, T., Maejima, Y., Haraguchi, G., Fukasawa, H., et al. (2004). Inhibition of IkappaB phosphorylation in cardiomyocytes attenuates myocardial ischemia/reperfusion injury. Cardiovasc Res 63, 5159. Otto, M. E., Belohlavek, M., Khandheria, B., Gilman, G., Svatikova, A., & Somers, V. (2004). Comparison of right and left ventricular function in obese and nonobese men. Am J Cardiol 93, 15691572. Panagia, M., Gibbons, G. F., Radda, G. K., & Clarke, K. (2005). PPAR-alpha activation required for decreased glucose uptake and increased susceptibility to injury during ischemia. Am J Physiol Heart Circ Physiol 288, H2677H2683. Pasceri, V., Wu, H. D., Willerson, J. T., & Yeh, E. T. (2000). Modulation of vascular inammation in vitro and in vivo by peroxisome proliferator-activated receptorgamma activators. Circulation 101, 235238. Pellieux, C., Montessuit, C., Papageorgiou, I., & Lerch, R. (2007). Inactivation of peroxisome proliferator-activated receptor isoforms alpha, beta/delta, and gamma mediate distinct facets of hypertrophic transformation of adult cardiac myocytes. Pugers Arch 455, 443454. Piper, H. M., Meuter, K., & Schafer, C. (2003). Cellular mechanisms of ischemia reperfusion injury. Ann Thorac Surg 75, S644S648. Planavila, A., Rodriguez-Calvo, R., Jove, M., Michalik, L., Wahli, W., Laguna, J. C., et al. (2005). Peroxisome proliferator-activated receptor beta/delta activation inhibits hypertrophy in neonatal rat cardiomyocytes. Cardiovasc Res 65, 832841. Poynter, M. E., & Daynes, R. A. (1998). Peroxisome proliferator-activated receptor alpha activation modulates cellular redox status, represses nuclear factor-kappaB signaling, and reduces inammatory cytokine production in aging. J Biol Chem 273, 3283332841. Puigserver, P., Wu, Z., Park, C. W., Graves, R., Wright, M., & Spiegelman, B. M. (1998). A cold-inducible coactivator of nuclear receptors linked to adaptive thermogenesis. Cell 92, 829839. Reddy, J. K., & Krishnakantha, T. P. (1975). Hepatic peroxisome proliferation: Induction by two novel compounds structurally unrelated to clobrate. Science 190, 787789. Ricote, M., Huang, J., Fajas, L., Li, A., Welch, J., Najib, J., et al. (1998b). Expression of the peroxisome proliferator-activated receptor gamma (PPARgamma) in human atherosclerosis and regulation in macrophages by colony stimulating factors and oxidized low density lipoprotein. Proc Natl Acad Sci USA 95, 76147619. Ricote, M., Huang, J. T., Welch, J. S., & Glass, C. K. (1999). The peroxisome proliferatoractivated receptor(PPARgamma) as a regulator of monocyte/macrophage function. J Leukoc Biol 66, 733739. Ricote, M., Li, A. C., Willson, T. M., Kelly, C. J., & Glass, C. K. (1998a). The peroxisome proliferator-activated receptor-gamma is a negative regulator of macrophage activation. Nature 391, 7982.

262

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263 Staels, B., Koenig, W., Habib, A., Merval, R., Lebret, M., Torra, I. P., et al. (1998). Activation of human aortic smooth-muscle cells is inhibited by PPARalpha but not by PPARgamma activators. Nature 393, 790793. Snghedauw, B. (1999). Molecular mechanisms of myocardial remodeling. Physiol Rev 79, 215262. Sugawara, A., Takeuchi, K., Uruno, A., Ikeda, Y., Arima, S., Kudo, M., et al. (2001). Transcriptional suppression of type 1 angiotensin II receptor gene expression by peroxisome proliferator-activated receptor-gamma in vascular smooth muscle cells. Endocrinology 142, 31253134. Tabernero, A., Schoonjans, K., Jesel, L., Carpusca, I., Auwerx, J., & Andriantsitohaina, R. (2002). Activation of the peroxisome proliferator-activated receptor alpha protects against myocardial ischaemic injury and improves endothelial vasodilatation. BMC Pharmacol 2, 10. Taegtmeyer, H. (1994). Energy metabolism of the heart: from basic concepts to clinical applications. Curr Probl Cardiol 19, 59113. Takeyama, D., Kagaya, Y., Yamane, Y., Shiba, N., Chida, M., Takahashi, T., et al. (1995). Effects of chronic right ventricular pressure overload on myocardial glucose and free fatty acid metabolism in the conscious rat. Cardiovasc Res 29, 763767. Tan, N. S., Shaw, N. S., Vinckenbosch, N., Liu, P., Yasmin, R., Desvergne, B., et al. (2002). Selective cooperation between fatty acid binding proteins and peroxisome proliferator-activated receptors in regulating transcription. Mol Cell Biol 22, 51145127. Teissier, E., Nohara, A., Chinetti, G., Paumelle, R., Cariou, B., Fruchart, J. C., et al. (2004). Peroxisome proliferator-activated receptor alpha induces NADPH oxidase activity in macrophages, leading to the generation of LDL with PPAR-alpha activation properties. Circ Res 95, 11741182. Tenkanen, L., Manttari, M., & Manninen, V. (1995). Some coronary risk factors related to the insulin resistance syndrome and treatment with gembrozil. Experience from the Helsinki Heart Study. Circulation 92, 17791785. Tian, Q., Grzemski, F. A., Panagiotopoulos, S., & Ahokas, J. T. (2006). Peroxisome proliferator-activated receptor alpha agonist, clobrate, has profound inuence on myocardial fatty acid composition. Chem Biol Interact 160, 241251. Todorov, V. T., Desch, M., Schmitt-Nilson, N., Todorova, A., & Kurtz, A. (2007). Peroxisome proliferator-activated receptor-gamma is involved in the control of renin gene expression. Hypertension 50, 939944. Tordjman, K., Bernal-Mizrachi, C., Zemany, L., Weng, S., Feng, C., Zhang, F., et al. (2001). PPARalpha deciency reduces insulin resistance and atherosclerosis in apoE-null mice. J Clin Invest 107, 10251034. Tordjman, K. M., Semenkovich, C. F., Coleman, T., Yudovich, R., Bak, S., Osher, E., et al. (2007). Absence of peroxisome proliferator-activated receptor-alpha abolishes hypertension and attenuates atherosclerosis in the Tsukuba hypertensive mouse. Hypertension 50, 945951. Vamecq, J., & Draye, J. P. (1989). Pathophysiology of peroxisomal beta-oxidation. Essays Biochem 24, 115225. van der Lee, K. A., Vork, M. M., De Vries, J. E., Willemsen, P. H., Glatz, J. F., Reneman, R. S., et al. (2000a). Long-chain fatty acid-induced changes in gene expression in neonatal cardiac myocytes. J Lipid Res 41, 4147. van der Lee, K. A., Willemsen, P. H., van, d. V., & Van, B. M. (2000b). Effects of fatty acids on uncoupling protein-2 expression in the rat heart. FASEB J 14, 495502. van der Wal, A. C., Das, P. K., Tigges, A. J., & Becker, A. E. (1992). Adhesion molecules on the endothelium and mononuclear cells in human atherosclerotic lesions. Am J Pathol 141, 14271433. Verges, B. (2004). Clinical interest of PPARs ligands. Diabetes Metab 30, 712. Verma, S., Bhanot, S., Arikawa, E., Yao, L., & McNeill, J. H. (1998). Direct vasodepressor effects of pioglitazone in spontaneously hypertensive rats. Pharmacology 56, 716. Verreth, W., Ganame, J., Mertens, A., Bernar, H., Herregods, M. C., & Holvoet, P. (2006). Peroxisome proliferator-activated receptor-alpha,gamma-agonist improves insulin sensitivity and prevents loss of left ventricular function in obese dyslipidemic mice. Arterioscler Thromb Vasc Biol 26, 922928. Vosper, H., Khoudoli, G. A., Graham, T. L., & Palmer, C. N. (2002). Peroxisome proliferator-activated receptor agonists, hyperlipidaemia, and atherosclerosis. Pharmacol Ther 95, 4762. Walker, A. B., Chattington, P. D., Buckingham, R. E., & Williams, G. (1999). The thiazolidinedione rosiglitazone (BRL-49653) lowers blood pressure and protects against impairment of endothelial function in Zucker fatty rats. Diabetes 48, 14481453. Wayman, N. S., Ellis, B. L., & Thiemermann, C. (2002a). Ligands of the peroxisome proliferator-activated receptor-PPAR-a reduce myocardial infarct size. Med Sci Monit 8, BR243BR247. Wayman, N. S., Hattori, Y., McDonald, M. C., Mota-Filipe, H., Cuzzocrea, S., Pisano, B., et al. (2002b). Ligands of the peroxisome proliferator-activated receptors (PPAR-gamma and PPAR-alpha) reduce myocardial infarct size. FASEB J 16, 10271040. Weatherford, E. T., Itani, H., Keen, H. L., & Sigmund, C. D. (2007). Is peroxisome proliferator-activated receptor-gamma a new pal of renin? Hypertension 50, 844846. Werman, A., Hollenberg, A., Solanes, G., Bjorbaek, C., Vidal-Puig, A. J., & Flier, J. S. (1997). Ligand-independent activation domain in the N terminus of peroxisome proliferator-activated receptor gamma (PPARgamma). Differential activity of PPARgamma1 and -2 isoforms and inuence of insulin. J Biol Chem 272, 2023020235. Wu, L., Wang, R., De, C. J., & Wilson, T. W. (2004). Benecial and deleterious effects of rosiglitazone on hypertension development in spontaneously hypertensive rats. Am J Hypertens 17, 749756. Wynne, A. M., Mocanu, M. M., & Yellon, D. M. (2005). Pioglitazone mimics preconditioning in the isolated perfused rat heart: A role for the prosurvival kinases PI3K and P42/44MAPK. J Cardiovasc Pharmacol 46, 817822. Xu, L., Glass, C. K., & Rosenfeld, M. G. (1999). Coactivator and corepressor complexes in nuclear receptor function. Curr Opin Genet Dev 9, 140147.

Ross, R. (1999). AtherosclerosisAn inammatory disease. N Engl J Med 340, 115126. Rubins, H. B., Robins, S. J., Collins, D., Fye, C. L., Anderson, J. W., Elam, M. B., et al. (1999). Gembrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein cholesterol. Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group. N Engl J Med 341, 410418. Sack, M. N., Rader, T. A., Park, S., Bastin, J., McCune, S. A., & Kelly, D. P. (1996). Fatty acid oxidation enzyme gene expression is downregulated in the failing heart. Circulation 94, 28372842. Sambandam, N., Morabito, D., Wagg, C., Finck, B. N., Kelly, D. P., & Lopaschuk, G. D. (2006). Chronic activation of PPARalpha is detrimental to cardiac recovery after ischemia. Am J Physiol Heart Circ Physiol 290, H87H95. Sato, H., Ishihara, S., Kawashima, K., Moriyama, N., Suetsugu, H., Kazumori, H., et al. (2000). Expression of peroxisome proliferator-activated receptor (PPAR)gamma in gastric cancer and inhibitory effects of PPARgamma agonists. Br J Cancer 83, 13941400. Satoh, H., Tsukamoto, K., Hashimoto, Y., Hashimoto, N., Togo, M., Hara, M., et al. (1999). Thiazolidinediones suppress endothelin-1 secretion from bovine vascular endothelial cells: A new possible role of PPARgamma on vascular endothelial function. Biochem Biophys Res Commun 254, 757763. Scandinavian Simvastatin Survival Study (1994). Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: The Scandinavian Simvastatin Survival Study (4S). Lancet 344, 13831389. Schiffrin, E. L. (2005). Peroxisome proliferator-activated receptors and cardiovascular remodeling. Am J Physiol Heart Circ Physiol 288, H1037H1043. Schmidt, A., Endo, N., Rutledge, S. J., Vogel, R., Shinar, D., & Rodan, G. A. (1992). Identication of a new member of the steroid hormone receptor superfamily that is activated by a peroxisome proliferator and fatty acids. Mol Endocrinol 6, 16341641. Schoonjans, K., Peinado-Onsurbe, J., Lefebvre, A. M., Heyman, R. A., Briggs, M., Deeb, S., et al. (1996a). PPARalpha and PPARgamma activators direct a distinct tissuespecic transcriptional response via a PPRE in the lipoprotein lipase gene. EMBO J 15, 53365348. Schoonjans, K., Staels, B., & Auwerx, J. (1996b). Role of the peroxisome proliferatoractivated receptor (PPAR) in mediating the effects of brates and fatty acids on gene expression. J Lipid Res 37, 907925. Schulman, I. H., Zhou, M. S., & Raij, L. (2006). Interaction between nitric oxide and angiotensin II in the endothelium: Role in atherosclerosis and hypertension. J Hypertens Suppl 24, S45S50. Schuster, H., Fagerberg, B., Edwards, S., Halmos, T., Lopatynski, J., Stender, S., et al. (2008). Tesaglitazar, a dual peroxisome proliferator-activated receptor alpha/ gamma agonist, improves apolipoprotein levels in non-diabetic subjects with insulin resistance. Atherosclerosis 197, 355362. Shalev, A., Siegrist-Kaiser, C. A., Yen, P. M., Wahli, W., Burger, A. G., Chin, W. W., et al. (1996). The peroxisome proliferator-activated receptor alpha is a phosphoprotein: regulation by insulin. Endocrinology 137, 44994502. Shepherd, J., Cobbe, S. M., Ford, I., Isles, C. G., Lorimer, A. R., MacFarlane, P. W., et al. (1995). Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group. N Engl J Med 333, 13011307. Sher, T., Yi, H. F., McBride, O. W., & Gonzalez, F. J. (1993). cDNA cloning, chromosomal mapping, and functional characterization of the human peroxisome proliferator activated receptor. Biochemistry 32, 55985604. Shimabukuro, M., Higa, S., Shinzato, T., Nagamine, F., Komiya, I., & Takasu, N. (1996). Cardioprotective effects of troglitazone in streptozotocin-induced diabetic rats. Metabolism 45, 11681173. Shimaya, A., Kurosaki, E., Shioduka, K., Nakano, R., Shibasaki, M., & Shikama, H. (1998). YM268 increases the glucose uptake, cell differentiation, and mRNA expression of glucose transporter in 3T3-L1 adipocytes. Horm Metab Res 30, 543548. Shu, H., Wong, B., Zhou, G., Li, Y., Berger, J., Woods, J. W., et al. (2000). Activation of PPARalpha or gamma reduces secretion of matrix metalloproteinase 9 but not interleukin 8 from human monocytic THP-1 cells. Biochem Biophys Res Commun 267, 345349. Sidell, R. J., Cole, M. A., Draper, N. J., Desrois, M., Buckingham, R. E., & Clarke, K. (2002). Thiazolidinedione treatment normalizes insulin resistance and ischemic injury in the Zucker fatty rat heart. Diabetes 51, 11101117. Sivarajah, A., McDonald, M. C., & Thiemermann, C. (2005). The cardioprotective effects of preconditioning with endotoxin, but not ischemia, are abolished by a peroxisome proliferator-activated receptor-gamma antagonist. J Pharmacol Exp Ther 313, 896901. Smeets, P. J., Planavila, A., van, d. V., & Van, B. M. (2007). Peroxisome proliferatoractivated receptors and inammation: Take it to heart. Acta Physiol (Oxf) 191, 171188. Smeets, P. J., Teunissen, B. E., Planavila, A., de Vogel-van den Bosch, Willemsen, P. H., van, d. V., et al. (2008a). Inammatory pathways are activated during cardiomyocyte hypertrophy and attenuated by peroxisome proliferator-activated receptors PPARalpha and PPARdelta. J Biol Chem 283, 2910929118. Smeets, P. J., Teunissen, B. E., Willemsen, P. H., van Nieuwenhoven, F. A., Brouns, A. E., Janssen, B. J., et al. (2008b). Cardiac hypertrophy is enhanced in PPAR alpha/ mice in response to chronic pressure overload. Cardiovasc Res 78, 7989. Smiley, L. M., Camp, T. M., Lucchesi, P. A., & Tyagi, S. C. (2004). Peroxisome proliferator ameliorates endocardial endothelial and muscarinic dysfunction in spontaneously hypertensive rats. Antioxid Redox Signal 6, 367374. Soutoglou, E., Viollet, B., Vaxillaire, M., Yaniv, M., Pontoglio, M., & Talianidis, I. (2001). Transcription factor-dependent regulation of CBP and P/CAF histone acetyltransferase activity. EMBO J 20, 19841992. Springer, T. A. (1994). Trafc signals for lymphocyte recirculation and leukocyte emigration: The multistep paradigm. Cell 76, 301314.

E. Robinson, D.J. Grieve / Pharmacology & Therapeutics 122 (2009) 246263 Xu, Y., Lu, L., Greyson, C., Lee, J., Gen, M., Kinugawa, K., et al. (2003). Deleterious effects of acute treatment with a peroxisome proliferator-activated receptor-gamma activator in myocardial ischemia and reperfusion in pigs. Diabetes 52, 11871194. Yagil, C., & Yagil, Y. (2007). Peroxisome proliferator-activated receptor alpha: Friend or foe? Hypertension 50, 847850. Yamamoto, K., Ohki, R., Lee, R. T., Ikeda, U., & Shimada, K. (2001). Peroxisome proliferator-activated receptor gamma activators inhibit cardiac hypertrophy in cardiac myocytes. Circulation 104, 16701675. Yeh, C. H., Chen, T. P., Lee, C. H., Wu, Y. C., Lin, Y. M., & Lin, P. J. (2006). Cardiomyocytic apoptosis following global cardiac ischemia and reperfusion can be attenuated by peroxisome proliferator-activated receptor alpha but not gamma activators. Shock 26, 262270. Young, M. E., Laws, F. A., Goodwin, G. W., & Taegtmeyer, H. (2001). Reactivation of peroxisome proliferator-activated receptor alpha is associated with contractile dysfunction in hypertrophied rat heart. J Biol Chem 276, 4439044395. Yue, T. L., Bao, W., Jucker, B. M., Gu, J. L., Romanic, A. M., Brown, P. J., et al. (2003). Activation of peroxisome proliferator-activated receptor-alpha protects the heart from ischemia/reperfusion injury. Circulation 108, 23932399.

263

Yue Tl, T. L., Chen, J., Bao, W., Narayanan, P. K., Bril, A., Jiang, W., et al. (2001). In vivo myocardial protection from ischemia/reperfusion injury by the peroxisome proliferator-activated receptor-gamma agonist rosiglitazone. Circulation 104, 25882594. Zahradka, P. (2007). Cardiovascular actions of the peroxisome proliferator-activated receptor-alpha (PPARalpha) agonist Wy14,643. Cardiovasc Drug Rev 25, 99122. Zhang, L., & Chawla, A. (2004). Role of PPARgamma in macrophage biology and atherosclerosis. Trends Endocrinol Metab 15, 500505. Zhu, P., Lu, L., Xu, Y., & Schwartz, G. G. (2000). Troglitazone improves recovery of left ventricular function after regional ischemia in pigs. Circulation 101, 11651171. Zhu, Y., Qi, C., Jain, S., Rao, M. S., & Reddy, J. K. (1997). Isolation and characterization of PBP, a protein that interacts with peroxisome proliferator-activated receptor. J Biol Chem 272, 2550025506. Zingarelli, B., Hake, P. W., Mangeshkar, P., O, Connor , M., Burroughs, T. J., Piraino, G., et al. (2007). Diverse cardioprotective signaling mechanisms of peroxisome proliferatoractivated receptor-gamma ligands, 15-deoxy-Delta12,14-prostaglandin J2 and ciglitazone, in reperfusion injury: role of nuclear factor-kappaB, heat shock factor 1, and Akt. Shock 28, 554563.