Dec 26, 2022
In this week’s Circulation on the Run podcast, we turn the show over to Circulation’s Social Media Editors Dr. Pishoy Gouda and Dr. Peder Myhre. They interview the 2022 recipients of the Joseph Loscalzo Award for Best Basic Science Article, and the 2022 recipients of the James T. Willerson Award for Best Clinical Article.
Dr. Maryjane Farr:
Welcome everybody to Circulation on the Run. My name is Maryjane Farr, and I'm the digital strategies editor at Circulation. Carolyn and Greg are on break this week. And as part of the Circulation tradition, we turn the stage over to two of our social media editors, Dr. Peder Myhre from Oslo and Dr. Pishoy Gouda from Edmonton. They're going to be interviewing the 2022 winners of the Loscalzo Award and the Willerson Award. Take it away, Peter and Pishoy.
Dr. Peder Myhre:
Today. Pishoy, we have a very exciting issue of Circulation on the Run. We are going-
Dr. Pishoy Gouda:
We certainly do.
Dr. Peder Myhre:
Yeah. We're going to discuss two amazing papers that are award-winning and we're going to talk to the first authors who really know these papers and conducted the amazing work that we're going to display here today.
Dr. Pishoy Gouda:
Yeah, I'm excited.
Peter. And with us today, we'll start talking about the recipients of the Loscalzo Award. So I wanted to start off by introducing Dr. Leo and Dr. Suvorava, who are the very proud recipients of the Loscalzo Award for their paper entitled Red Blood Cell and Endothelial eNOS Independently Regulate Circulating Nitric Oxide Metabolites and Blood Pressure. So welcome Doctors Leo and Suvorava. How are you guys doing today?
Dr. Francesca Leo:
Hi, thank you for the introduction and pretty well, I'm currently in Italy for my winter Christmas holidays, but I'm really excited and happy to be here today with you.
Dr. Pishoy Gouda:
Excellent.
Dr. Suvorava:
Hello. I'm also very happy to be here today. Thank you for your invitation and for your congratulations. It's a privilege and honor for me to be a recipient of this Dr. Loscalzo Award. Thank you.
Dr. Pishoy Gouda:
Well, I just wanted to start off by taking another second here to congratulate you both on this award. We all know the sheer amount of work and dedications to get these projects going, so congratulations. And I'm going to start off with a really easy question for you guys. When you found out that you were a recipient of the Loscalzo Award, who is the first person that you told?
Dr. Francesca Leo:
As I mentioned, I'm Italian and as a good Italian I need to say that. Of course, the first people I told were my parents because we all know that Italian and parents are just one thing. So they were the first ones. And then all of course, my partner and friends came second, parents first, family first.
Dr. Pishoy Gouda:
Very good. What about yourself, Tatsiana?
Dr. Tatsiana Suvorava:
Hi. Yeah. I had to think back like seven years ago and I very good remember one day when I was really excited about the results, what we found, I was in the lab, I was developing a western blood to check the functional ability of our models and it showed that it was very successful that we couldn't knock out our protein of interest almost completely. And at that day exactly, we had a lab meeting. So I directly pulled this image on my USB stick and then showed it on the lab meeting. So actually these were my colleagues who first hear about this.
Dr. Pishoy Gouda:
That's awesome. That's lovely. Well, after I got married, sometimes my parents get bumped to the second phone call and they weren't very happy about that and they let me know very clearly. But let's switch gears a little bit and tell us a little bit about how you made the decision to pursue academics. It's such a daunting career and a daunting topic sometimes. And how did you get interested in research and how did you find yourself coming into this research project?
Dr. Francesca Leo:
If I can start first. Well, I decided to pursue an academical career at the beginning following my master thesis that I did at the University of Pisa here. And I've always wanted to go abroad and gain experience, get to know different realities apart from Italy. And I was actually really lucky that I got the opportunity to work in the laboratory Professor Cortese-Krott because that gave me the opportunity to grow a lot, both personally and professionally, of course. I learned new techniques and together with our great team, we managed to achieve many goals. In particular, this paper, I must say that was my last satisfaction before my doctoral exam. So I think the feeling that you get after any also small achievement is something that you can really, I cannot find it hard to explain to people that are not in research or not in science in general.
Dr. Pishoy Gouda:
No, I totally agree. When I get a new data set, I get so excited and my wife is telling me, what are you doing is I just got new data and I'm like a little child on Christmas day. She doesn't understand it, but she appreciates that some people like that. What about yourself? What about yourself?
Dr. Tatsiana Suvorava:
Yeah, well my decision to pursue academic career started with as probably for many researchers, started from intense fascination from one discovery. I was at the beginning of my bachelors' science studies and then the Nobel Prize was given for the discovery of nitric oxide as a signaling molecule in a cardiovascular system. And I was so fascinated that the gaseous molecule so simple has so lots of responsibility in the body. And since that time, that was always in the focus of my research and this is for me, a lifelong journey. I'm still on the way.
Dr. Pishoy Gouda:
That's amazing, Tatsiana. And that sort of sets us up nicely. And as you guys know, I'm a interventional cardiologist. Basic science is a little bit farther from my memory. So I'll start off by admitting that my basic science research is not where it should be. But with that in mind, I was wondering if you could just tell our listeners a little bit about your research and why this question is so important and explain it to you like you were lowly clinicians that don't really understand basic science.
Dr. Francesca Leo:
I always take over Tanya, but yes, I have less to say than you. I must admit.
Dr. Tatsiana Suvorava:
Okay so let’s start. No problem.
Dr. Pishoy Gouda:
It's a team effort. It's a team effort.
Dr. Tatsiana Suvorava:
Its a team effort and yeah. Ok.
Dr. Francesca Leo:
It's been a really teamwork, I must say from the really, really, really beginning. So this paper was, as I said, the central focus of my doctoral thesis. I just take two small part of it, of course, in particular, what is really important on the paper, I think that is we use really new mice models that Tanya and my Professor Cortese-Krott really and highly characterized at the really beginning, so developed completely from new, and they are mice that are expressing or not eNOS this protein that is responsible for nitric oxide production in the endothelium or in red blood cells. So the importance of this research was to demonstrate the role or pivotal role of eNOS expressed in the red blood cells in the modulation of blood pressure as well as circulating nitric oxide metabolites. And we actually did it with this paper. And considering that cardiovascular disease are one of the major causes of death nowadays, this results can really have important clinical and therapeutical implications for future research and real life, let's say.
Dr. Tatsiana Suvorava:
Yeah, maybe I could add to Francesca.
Dr. Francesca Leo:
Sure,
Dr. Tatsiana Suvorava:
Yeah.
Dr. Pishoy Gouda:
Of course.
Dr. Tatsiana Suvorava:
I think our research was especially important because it's identified the existence of previously unrecognized and actually non-canonical pathway, how the red blood cells can regulate blood pressure. And it was so exciting about this.
Dr. Pishoy Gouda:
Right. So trying to find out if the red blood cell, nitric oxide synthase can actually regulate blood pressure. And this has obviously lots of clinical implications. So in practice, how did you guys set up your experiments? How did you try to test the significance of the Enos red blood cells effects?
Dr. Francesca Leo:
Just if I can add something, what was really important. So what is known is that Enos expressing the endothelium plays an important role in the modulation of blood pressure. What we actually found out is that the one in the red blood cells also is involved and played a role that seems to be independent from the one played from the eNOS expressed in the endothelium. For answering your question, I also, I need to say I'm not the right candidate because this is a huge project that started about 10 years ago. So I was really, I repeated and I will always repeat it, I was really lucky to take part to this project and to get the opportunity to take part to this journey because it was really a journey and it gave me the opportunity to work with very different people and get in touch with very different realities, academical realities.
And I can say that this project started from my previous boss and Tanya that they had this idea and started this whole project together with, of course Tanya is the one that is involved since the really beginning. So she can definitely better answer to this question.
Dr. Tatsiana Suvorava:
Yeah, thank you, Francesca. It's a long way actually what we did, and actually I started this particular project on the level of postdoc and eNOS and hypertension have been already in a center of my research interest for several years. And in a previous project what I had, I also had a transgenic mice, which were generated by conventional genetic approach by micro injection of D N a. And at that time we observed a significant contribution of external endothelial component into the blood pressure regulated. However, at that time we were not able to identify the exact extracellular allocation of this component. There were several candidates which were suggested, and one of them there were red blood cells. And everyone was kind of skeptical about this because the level of eNOS protein in red blood cells is extremely low. And furthermore, there were a lot of doubts how eNOS activity can be exported from the red blood cells because it's red blood cells are full of heme, which is a scavenger of nitric oxide.
Furthermore, actually it was not clear how they transported and how it is released this activity. But now if we think that red blood cells are the largest component contributor to overall cell number in the body, so maybe then we can more critically think and then think that the total amount of red blood cells maybe compensate for this very low eNOS protein expression. And actually because they have a high density and their shape is erase high, so they provide a very sufficient release of this inactivity from red blood cells. But this idea was doubted for many years, although there it was reported that eNOS is expressed in red blood cells in 2006 was a paper.
Dr. Pishoy Gouda:
Well that's very exciting. So what we really learned is that eNOS system in both red blood cells and endothelial cells contribute to blood pressure regulation. Now I might direct this to you, Francesca. Well what does that mean for the clinicians in our audience? Well, what does that mean for a hypertension patients?
Dr. Francesca Leo:
So for clinicians, so, I must say these findings may have really important pathophysiological implication in the understanding of the interrelationships between hematologic and cardiovascular disease and may reveal the really novel therapeutic approaches to improve tissue perfusion. Moreover, our data and models may also help in understanding how red blood cells eNOS signaling can really affect red blood cells function, the scavenging of nitric oxide, as Tanya had previously said, as well as the crosstalk between nitric oxide and the sulfides that are of highly present in the bloodstream and in the body as well as oxygen transport. And may also enable us to refine the criteria for blood banking transfusion and to also try to develop new strategies or therapies for many diseases and pathologies where red blood cells are involved.
For example, coronary artery disease, chronic kidney disease that normally are pathologists that show a decrease in the expression of eNOS expressed in the red blood cells or hematologic disease hemoglobinopathies, which are normally characterized by a systemic decrease in nitric oxide bioavailability or one of the most common diseases, sickle cell disease. Cause of course the shape of red blood cells is definitely also responsible of their functioning. And it can also determine, of course, an impairment or more alteration in the release of nitric oxide in the body.
Dr. Tatsiana Suvorava:
Yeah, maybe I'll just add few words. So actually that's open as a perspective that impairment of red blood cells, eNOS may contribute to the pathogenesis of hypertension. So this is the most important thing I think here in clinician point of view.
Dr. Pishoy Gouda:
Yeah, absolutely. Lots of different ways that this research might be heading. And like you were saying earlier, Tatiana research is really a longitudinal process. You started this almost a decade ago and I'm sure that there's more projects and plans that you have with this for the future. What are you working on now?
Dr. Tatsiana Suvorava:
Well, I'm still in academia and I'm still doing academic career, actually. We continued our study and we also studied pathophysiological significance of red blood cells eNOS for cardio protection. For example, in regulation of coronary blood flow, myocardial performance in myocardial infarction, acute myocardial infarction in vivo. We recently published this and here we could also see involvement of red blood cells eNOS, which limit infarct size in acute myocardial infarction. In a pipeline is also a manuscript about red blood cells and endothelial cells eNOS in exercise induced cardio protection and of course the other focus would be the role of red blood cells eNOS in other disease conditions and a chronicle kidney disease for example. It will be also investigated. So we are full of plans, however, I changed department, but I'm still having eNOS in focus and hypertension as well.
Dr. Pishoy Gouda:
Well that's really exciting stuff and yes, I just wanted to congratulate you both again Dr. Leo and Suvorava and thank you for taking the time to share with us your very clear passion for this topic and I wish you guys both the best of luck. Congratulations again.
Dr. Francesca Leo:
Thank you so much.
Dr. Tatsiana Suvorava:
Thank you so much.
Dr. Pishoy Gouda:
Well congratulations again to our award recipients and Peter, why don't you tell us a little bit about what article we're going to be talking about next?
Dr. Peder Myhre:
Yes, thank you so much Pishoy. And first, I must say it was so much fun to listen to you guys discuss the paper. You can really feel the passion for the science coming through the microphone. And that was for me as a clinician as well. I learned a lot. And now we're going to actually take a step and move over back to clinical science and we are going to talk to the winners of the James T. Willerson Award. So welcome doctors, Jeanne du Fey and Dr. Alexandra Prepoudis.
Dr. Jeanna du Fay de Lavallaz:
Thank you very much for having us on the podcast. It's a pleasure to be here and we're also very happy to be able to discuss this paper with you. And of course we were extremely glad to receive this award, so we're excited about the discussion.
Dr. Peder Myhre:
And so for the listeners who are not familiar with the Willerson Award, this award recognizes the best clinical paper published in circulation in the preceding 12 months. And this award honors Dr. Willerson, who was a major leader within American Heart Association. And among his roles, he served for over a decade as the editor-in-chief of circulation. And during his tenure, the journal transitioned away from a once monthly format, vastly expanded its international footprints and rose substantially in stature and impact. And speaking of international footprint, today we have authors from all over the world and I know both of you, Jeanne and Alexandra are from the amazing biomarker group in Basel led by Christian Mueller. So Alexandra, if we can start with you, I just want to learn a little bit more about you. Where do you work, where are you in your career and your areas of interest?
Dr. Alexandra Prepoudis:
Good evening and thank you for the introduction. My name is Alexandra Prepoudis and I'm currently a cardiology fellow at the University Hospital of Basel in Switzerland. I have always been very interested in clinical research, so I decided to join the group of Professor Christian Mueller in Basel for a year prior my residency in internal medicine. And that's how I met Jeanne and the whole study team.
Dr. Peder Myhre:
Very nice. And Jeanne, what about you?
Dr. Jeanna du Fay de Lavallaz:
So my name is Jeanne du Fey and I'm currently also a cardiology fellow at the hospital in Zurich. I moved a little bit, but my main research is still based in Basel. You don't leave Professor Mueller's group once you're in it. So I sticked around. So I am undertook physician scientist track after med school and for my MD PhD I was very lucky to integrate Dr. Mueller's group into the paper we are going to discuss tonight is actually the very first study that I designed during my PhD of course with a lot of help from the whole group of Professor Mueller, professor Mueller himself and of course Alexandra who joined a little bit later and really helped us tackle quite a big piece of the biomarker research that I'm very excited to talk about.
Dr. Peder Myhre:
So that is amazing. So this is the first paper you designed and what a wonderful debut because today we're going to discuss this award-winning paper and it is entitled Skeletal Muscle Disorder and Non-Cardiac Source of Cardiac Troponin T. And of course we are within the field of troponin and I must admit Jeanne and Alexandra that I myself is a troponin nerd myself. I love research and learning more about troponin and for me this paper was really something I was eager to learn more about because we've all been questioning what is the impact of skeletal muscle disease on troponin. So perhaps Jeanne, if you could start to explain the background for this study, and what was the research question?
Dr. Jeanna du Fay de Lavallaz:
So in the past years, I think there were quite a few reports. These were mostly case series of what you have just mentioned. So it's this observation that skeletal muscle disease might actually have an impact on some troponin measurements and we were not exactly sure which. So there are these two main isophones of troponin, the troponin T and the troponin I. Depending on the hospital, depending on the country, one of both might be measured either the troponin I or the troponin T. And then for troponin T we have only one essay and then for troponin I there are several of them. So there is kind of a big mix up there of what is possibly obtainable to assess cardiovascular health and basically also more coronary health, well cardiovascular health in patients that we see every day in the clinic.
And well, as you just mentioned, we had noticed in the past that sometimes it's troponin T was behaving in weird way in patients that were also suffering of some muscle skeletal muscle disease. So Prof. Mueller is leading a very large group biomarkers on troponin research and this is something that we decide to tackle in a very structured way in order to be able to rehab an answer and bring something to the field that might be maybe a little bit more consistent than this, however very interesting case series, but that were maybe a little bit done on very specific disease and a little bit all over the place.
Dr. Peder Myhre:
Exactly, and this is exactly what really made this paper so amazing is that first of all, you structured the clinical part of it with a prospective cohort. You did multiple essays on the patients and you even included some translational work on top of that, which is truly amazing. So I was wondering, Alexandra, if you perhaps could start with explaining the clinical part of the study, the patient cohort, the mythology use, et cetera. So please, Alexandra.
Dr. Alexandra Prepoudis:
We enrolled patients with muscle complaints. So for example, muscle pain, weakness, stiffness or fasciculations. And we enrolled them at four sites in two countries, most of them during ambulatory visits. And from each patient we collected a blood sample and we measured four different high sensitivity cardiac troponin assays. So one for troponin T and three for troponin I. Then patients underwent the cardiac workup including E C T, echo cardiography and cardiac M R I depending on the clinical indication. As a control group, we used patients from a prior study where patients who presented to the emergency department with the leading symptom of chest pain were enrolled. So of these we analyzed patients without skeletal muscle disease in whom a cardiac cause of chest pain could be excluded.
Dr. Peder Myhre:
Great. So really a big and well pheno typed group of patients. And before we go to the results, we're going to also learn a little bit about the experimental part of the study that you conducted. So Jeanne, if you would just explain what was, this was something with the gene expression in the muscles, right.
Dr. Jeanna du Fay de Lavallaz:
So we decided to be a little bit original and to bring it back to the bench instead of bringing it to the bedside as we usually do. And-
Dr. Peder Myhre:
I love it.
Dr. Jeanna du Fay de Lavallaz:
We will soon. We were also very lucky to have amazing collaborators because that allowed us to collaborate with a rheumatologist with neurologists. And these doctors might have in the past collected some muscle tissue for completely different muscle analysis. So in order to phenotype the diseases that the patients were actually suffering of and we're also lucky enough so that there was sometimes some of this muscle tissue is still available and we basically extracted mRNA from these skeletal muscle samples. And what we looked at was the mRNA of the different troponin genes that we could find in there. So as you probably know, there is some genes coding for skeletal troponin and there are some genes coding for cardiac troponin. And what we could see that was, we might come to that in the results, but basically our goal was to look at the expression of the different skeletal or cardiac troponin in these skeletal muscle samples.
Dr. Peder Myhre:
Exactly. And the next question is going to be difficult because I want you to summarize the findings and there are so many findings to supplement. This is really, it's like pressure. But please Alexandra, can you try to summarize the primary results of this paper?
Dr. Alexandra Prepoudis:
Yes, of course. I will try my best. So maybe first about half of the cohort showed the cardiac disease IE the coronary heart disease, atrial fibrillation, or chronic heart failure. So cardiomyocyte injury resulting from cardiac disease was a major contributor to elevated troponin T and I concentrations even in these patients with skeletal muscle disorders. But troponin T concentrations were above the upper limit of normal in about 55% and the concentrations were significantly higher compared with control subs checked. While troponin I concentrations were elevated to a significantly lower percentage, which were also comparable to the concentrations in the control group. Also, we found that the elevated troponin T concentrations were restricted largely to patients with non-inflammatory myosis and myositis. And maybe one thing to the gene expression regarding the gene expression analysis, we found the eightfold up regulation for the gene and coding for cardiac troponin T in skeletal muscle compared with controls without skeletal muscle disease.
Dr. Peder Myhre:
Wow, that is so great. So please let me try to summarize these important findings to the listeners. So you actually found in patients with skeletal muscle disease, a much higher level of troponin T compared to healthy controls or at least controls without myocardial infarction. And for troponin, these differences were not that pronounced. So that means gene, that troponin T in patients with certain types of skeletal muscle disease may be falsely positive. Is that correct? And how would you put these findings in relation to previous studies in the field and also perhaps some clinical implications of the findings?
Dr. Jeanna du Fay de Lavallaz:
So yeah, I think we can say that in the patient where that was the case, this is actually falsely positive because when we talk about cardiac troponin T, cardiac troponin, we expect it coming from the heart, certainly not from the muscle of the patients or at least it's what cardiologists have been trying to not diagnose in the past years by refining also the assays that we were using so that it doesn't cross-react with anything coming from a skeletal muscle. And I think regarding previous studies in the field, so we tackled, I believe several aspect with this paper that hadn't really been well investigated before. And our study design helped with that a lot. So first we included patients based on their complaints that was not a specific cohort with a certain type of disease. We really enrolled them if they presented with some muscle complaints, so not a specific already diagnosed disease.
So this was the first point. And then second also, we investigated several troponin I assays, which also allowed us to have a broader observation of how this assay are actually interacting also with each other or how they relate to this troponin T assay, which is the only one existing. And then finally, I think this translational part with the MRN analysis really helped us to go back to the primary hypothesis, how does that work? Why is this the case at all? And finding this re-expression of the cardiac troponin T in the skeletal muscle really tells us that this might actually not be a problem with the assay itself but might really be that we have some cardiac troponin T circling in the blood and being measured by a perfectly well working assay, which is a totally different mechanism than for instance, cross reaction that we might sometimes observe for instance, with troponin I assays.
Dr. Peder Myhre:
Exactly. And the findings were so consistent across the 3 troponin I assays and supported by the biopsy findings, I think they were so robust. And you know, we're talking about how this might impact adjudication of a suspected myocardial infarction, but also troponin is a very strong prognostic marker within chronic conditions and in ambulatory patients. And even there it may really impact the utility of troponin as a risk marker. Alexandra, don't you think so?
Dr. Alexandra Prepoudis:
So, to come back to the first part of your question, what about patients with myocardial infarction? Our study did not directly investigate the impact of these unexpected troponin T concentrations on the diagnosis of myocardial infarction. But we believe that it's reasonable to say that if patients with a known chronic skeletal muscle disease present with chest pain to for example the emergency department and the first troponin T comes back elevated, the clinician should be aware that the skeletal muscle can be a possible source of this biomarker. So if possible, a troponin I should be obtained in these patients.
Dr. Peder Myhre:
Excellent. And that brings us to the last question of today, I think Jeanne, and that is the future direction of this field. We now know, I think for certain that some skeletal muscle disease have an elevated cardiac troponin T, or perhaps not cardiac, but at least troponin T. So what do we need to learn more about this? And is there any way we can improve the assays? Please, Jeanne, let me know your thoughts about the future.
Dr. Jeanna du Fay de Lavallaz:
So that's a complex question. I think already we are kind of running into troubles when we already just see the current situation with these assays. Depending on the countries, depending on the hospitals, depending on the laboratory background that all the laboratory measurement system that we might have. Some hospitals have a total different approach on which troponin to measure and what's troponin to make available for their physicians. But I think these biomarkers haven't finished to surprise us and also most likely to bring us some very good prognostic tools. And I believe once we can really refine the exact origin of which elevation in which patient and what this does imply for their prognosis, we might also be able to just predict much better where with our patients are going, what kind of diagnostic or treatments that we need to use in order to improve their life on the short and long term. So I have quite a lot of hope for these different assays to be better understood in the coming years.
Dr. Peder Myhre:
What a wonderful way to finalize this podcast. Jeanne and Alexandra, thank you so much for participating and for sharing your knowledge in the field and to learn about your current situation with work and your choices of career. And also a big thank you to Francesca and Tanya for the winners of the LOSCALZO Award for sharing their research. So on behalf of Pishoy and myself, I want to thank everyone for listening and thank you to the amazing authors and winners of the awards. This is Peter Myra, and on behalf of myself and Pishoy Gouda, we thank you for listening.
Dr. Greg Hundley:
This program is copyright of the American Heart Association 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.