European Journal of Heart Failure (2009) 11, 444452 doi:10.

1093/eurjhf/hfp042

REVIEW

Oxidative stress and hyperuricaemia: pathophysiology, clinical relevance, and therapeutic implications in chronic heart failure
Corinna Bergamini, Mariantonietta Cicoira*, Andrea Rossi, and Corrado Vassanelli
Department of Biomedical and Surgical Sciences, Division of Cardiology, Ospedale Civile Maggiore, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy Received 11 September 2008; revised 5 January 2009; accepted 2 March 2009; online publish-ahead-of-print 4 April 2009

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Heart failure (HF) is a state of chronic deterioration of oxidative mechanisms due to enhanced oxidative stress and consequent subcellular alterations. In this condition, oxidant-producing enzymes, in particular xanthine oxidase (XO), the major cardiovascular source of reactive oxygen species (ROS), are up-regulated. Growing evidence shows that this impaired oxidative metabolism due to enhanced ROS release is implicated in the development of cardiac hypertrophy, myocardial brosis, left ventricular remodelling, and contractility impairment responsible for worsening of cardiac function in CHF. Uric acid (UA) has long been linked with cardiovascular diseases, and hyperuricaemia is a common nding in patients with CHF. Hyperuricaemia is associated with impairment of peripheral blood ow and reduced vasodilator capacity, which relate closely to clinical status and reduced exercise capacity. Recent studies also suggest an association between UA levels and parameters of diastolic function; more importantly, UA has emerged as a strong independent prognostic factor in patients with CHF. In this review, we describe the up-to-date experimental and clinical studies that have begun to test whether the inhibition of XO translates into meaningful benecial pathophysiological changes. This treatment gives evidence that myocardial energy, endothelial dysfunction, and vasodilator reactivity to exercise are improved by reducing markers of oxidative stress responsible for vascular dysfunction, so it represents an interesting therapeutic alternative for better outcome in CHF patients.

----------------------------------------------------------------------------------------------------------------------------------------------------------Keywords
Oxidative stress Ventricular function Treatment

Introduction
Heart failure (HF) is the pathophysiological state in which the heart is unable to pump blood at a rate commensurate with the requirements of metabolizing tissues, or can do so only from an elevated lling pressure. A complex series of neurohormonal changes takes place as a result of the two principal haemodynamic alterations occurring in this condition: reduction of cardiac output and atrial hypertension. In the early stages of acute systolic failure, these changesheightened adrenergic drive, activation of the renin angiotensin aldosterone axis, and augmented release of vasopressin and endothelinare truly compensatory, maintaining perfusion to vital organs and increasing the inadequate arterial blood volume. As HF becomes chronic, several of these compensatory mechanisms can cause undesirable effects such as excessive vasoconstriction, increased afterload, excessive retention of salt and water, electrolyte abnormalities, and arrhythmias.1 HF is also a state of chronic deterioration of oxidative mechanisms due to enhanced oxidative stress and consequent subcellular

alterations. Oxidative stress can be dened as the condition in which excessive production of reactive oxygen species (ROS) a family of molecules including molecular oxygen and its derivatives which are produced in all aerobic cells, outstripping endogenous antioxidant defence mechanismshas been implicated in processes in which they oxidize biological macromolecules. The pathophysiological effects of ROS depend on the type, concentration, and specic site of production and involve three broad types of action. When the local levels of ROS are high, they tend to react with numerous protein centres, DNA, cell membranes, and other molecules, causing considerable cellular damage as well as generating other more reactive radicals. At lower concentrations, however, local targeted production of ROS serves as a secondmessenger system that transmits biological information through the highly specic modulation of intracellular signalling molecules, enzymes, and proteins (redox signalling function). The third general ROS-related pathophysiological mechanism involves the reaction of O2 with the signalling molecule nitric oxide (NO), 2

* Corresponding author. Tel: 39 0458123706, Fax: 39 045914727, Email: mariantonietta.cicoira@univr.it Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org.

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and Ca2 ATPase of SR. These effects would induce a decrease in cardiac contractility and in the rate of relaxation of cardiac muscle. Another mechanism causing a decrease in myocardial contractility might be the cell damage produced by oxygen free radicals, leading to peroxidation of membrane phospholipids, which can result in an increase in membrane uidity, increasing permeability, and loss of membrane integrity.12 14 Oxidant-producing enzymes are up-regulated in congestive HF, and either the quantity or spatial localization of NO-producing enzymes (NOSs and XO) is altered. A relative NO deciency may further promote oxidase activities, which suggests that NO may be a global modulator of oxygen free radicals.15 In the presence of O2, NO reacts to produce peroxinitrite (ONOO2), 2 which inhibits XO function primarily by oxidative disruption of the molybdenum catalytic site, reducing its activity and production of oxygen free radicals.16 If endothelial function is preserved and oxidative stress is low, NO activity would be expected to be sufcient to put a brake on XO activity. This regulatory control mechanism is effective as long as XO does not generate superoxide anion. This process may occur in the presence of hypoxia when the enzyme transfers electrons to molecular oxygen rather than to NAD during the different stages of purine metabolism.17 Under these conditions, increases in superoxide may inactivate NO, reducing its control over vascular oxidase,12 suggesting an important underlying mechanism in the development of vascular endothelial dysfunction in CHF, which contributes to systemic vasoconstriction and increased cardiac loading. Growing evidence also suggests an important role for increased oxidative stress in adverse left ventricular remodelling after myocardial infarction (MI),18,19 and in experimental models it has been shown that various antioxidant approaches can ameliorate this reverse remodelling, improving contractile function, reducing left ventricular dilatation, and lowering mortality.20,21 A signicant factor for the detrimental effect of ROS in this setting is the activation of matrix metalloproteinases, which drive matrix turnover and promote left ventricular dilatation. Oxidative stress may be critical in the activation of apoptosis, which is thought to be an important contributor to the progression of CHF especially in its advanced stages.

which in health has a central role in vascular homeostasis as well as in modulating cardiac function.2 The major cardiovascular sources of ROS include the enzymes xanthine oxidoreductase (XOS), NAD(P)H oxidase, and NOS, as well as mitochondrial cytochromes and haemoglobin. Xanthine oxidoreductase, a molybdenum-containing enzyme, is expressed as a 150 kDa homodimer that produces superoxide or hydrogen peroxide as by-products of the terminal steps of purine metabolism. The enzyme has two isoforms: xanthine oxidase (XO) and xanthine dehydrogenase (XDH). Xanthine oxidase is a variant of XDH, resulting from either irreversible proteolytic cleavage or reversible oxidation of sulfydril residues of XDH. Whereas XDH uses NAD as a cofactor (reducing it to NADH), XO utilizes molecular oxygen (reducing it to O2/H2O2).3 2 Although their role in the pathogenesis of clinical HF remains unclear, ROS have been implicated in most processes thought to have a signicant effect on cardiac function. Growing evidence implicates redox-sensitive pathways in the development of cardiac hypertrophy in response to either neurohumoral stimuli or chronic pressure overload. In cultured cardiomyocytes, hypertrophy induced by angiotensin II, endothelin I, norepinephrine, tumour necrosis factor a, or pulsatile mechanical stretch has been shown to involve intracellular ROS production and to be inhibited by antioxidants. The mechanism is related to ROSmediated activation of various mitogen-activated protein kinases and the transcription factor nuclear factor-kB.4 In vivo, the development of experimental pressure overload left ventricular hypertrophy (LVH) in mice or guinea pigs is attenuated by antioxidants, implying a role for ROS.5 Excess interstitial brosis is an important detrimental aspect of chronic LVH and chronic heart failure (CHF). Oxidative stress is well known to be pro-brotic in many organs, and recent work suggests that Nox2 oxidase-derived ROS are centrally involved in the development of interstitial cardiac brosis.6 In Nox2decient mice subjected to angiotensin II infusion, interstitial brosis was virtually abolished compared with wild-type mice. A similar inhibition of interstitial brosis was found in a model of aldosterone infusion, either in Nox2 knockout mice or in animals treated with NADPH oxidase inhibitor, apocynin.7,8 Interstitial cardiac brosis was also inhibited in Nox2 knockout mice subjected to aortic banding.9 Multiple underlying mechanisms are likely to be involved in these Nox2-dependent pro-brotic effects, including increased expression of pro-brotic growth factors and genes, increased activation of NF-kB, activation of matrix metalloproteinases, and inammatory cell inltration. Contractile impairment is a central feature of CHF and has a multifactorial basis, involving changes in cardiomyocytes function as well as altered chamber structure and properties. In vitro studies have shown that myocyte contractile function may be impaired by increased ROS through several mechanisms. In particular, the production of ROS by XO has potential pathophysiological relevance: their production by this enzyme leads to a worsening of cardiac function and of indices of myocardial contractility that might be due to oxygen free radicals depressing the excitationcontraction coupling mechanism in cardiac muscle.10 Hess et al.11 reported that oxygen free radicals generated by XO depressed Ca2 accumulation by sarcoplasmatic reticulum (SR)

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Hyperuricaemia: mechanisms and clinical consequences in heart failure

Uric acid (UA) is the end-product of purine metabolism catalysed by XO from hypoxanthine or xanthine (Figure 1). Uric acid is primarily excreted through the kidney, where it is completely ltered at the glomerulus, completely reabsorbed in the proximal tubule, then secreted (50% of the ltered load), and nally reabsorbed. Normal serum UA levels are generally ,7 mg/dL for men and ,6.5 mg/dL for women. Hyperuricaemia is a very common metabolic disorder. Elevated serum UA levels occur in 218% of the population, varying in relation to age, sex, and many other factors. It is mainly due to reduced excretion of UA, but in many cases the exact mechanism is not fully understood. High serum UA levels have been observed in hypoxic states,

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Figure 1 Purine metabolism. Purines arise from metabolism of dietary and endogenous nucleic acids and are degraded ultimately to uric acid
through the action of the enzyme xanthine oxidase.

Figure 2 Diagram showing renal excretion of uric acid. Uric acid is completely ltered at the glomerulus, immediately fully reabsorbed from
the proximal tubule, then secreted back into the proximal tubule (50% of the ltered load), and nally, 40% of the ltered load is reabsorbed. This leaves 10% of the ltered load excreted in the urine.

such as in obstructive pulmonary disease,22 neonatal hypoxia,23 cyanotic heart disease,24 and acute25 or CHF. Hypoxia and impaired oxidative metabolism contribute to enhanced UA levels. Hypoxia leads to accumulation of its precursors, hypoxanthine and xanthine,26 and activation of XDH and XO. Uric acid has long been linked with cardiovascular disease,27,28 35 and several potential mechanisms have been identied to explain this association. Serum UA may increase in patients with failing circulation because of increased generation, decreased excretion, or a combination of the two. There are several possible contributors to increased UA production in HF, including increased abundance and activity of XO,36 increased conversion of XDH to XO,37 or an

increase in XO substrate resulting from enhanced ATP breakdown to adenosine and hypoxanthine. A decrease in renal perfusion can also lead to increasing UA levels. As advancing HF leads to tissue ischaemia and a rise in serum lactate, renal UA excretion can be further impaired as lactate competes with urate via an organic anion exchanger in the proximal tubule38 (Figure 2). Although the liver is the principal source of UA, the endothelium also contributes to its production. In the heart, XO is localized solely in the capillary endothelium.39 Therefore, the UA generated in hypoxic states originates from capillary endothelial cells, rather than from the myocardium,40 and hyperuricaemia in HF may reect the metabolic effects of hypoxia on the microvasculature.

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control in cardiovascular disorders. Hyperuricaemia, especially in cachectic patients, in whom protein degradation and muscle wasting inuence UA production, correlates with increased postischaemic vascular resistance. Doehner et al. assessed leg resting and post-ischaemic vascular resistance (calculated from mean blood pressure and leg blood ow by venous occlusion plethysmography) in 23 cachectic and 44 non-cachectic patients with CHF and 10 healthy control subjects.50 The cachectic patients had the highest UA levels, compared with the non-cachectic patients and controls (612 + 36 vs. 459 + 18 and 346 + 21 mmol/L, respectively, both P , 0.0001), and the reduction in relative leg vascular resistance after ischaemia was lowest in cachectic patients (283% + 2%) compared with both non-cachectic patients (288% + 1%) and healthy control subjects (290% + 1%, both P , 0.005). In all patients, post-ischaemic vascular resistance correlated signicantly and independently of age with UA (r 0.61), creatinine (r 0.47, both P , 0.0001), peak VO2 (r 20.34), and New York Heart Association class (r 0.33, both P , 0.01). This correlation was not found in the healthy control subjects (r 20.04, P 0.9). In multivariate and stepwise regression analyses, serum UA emerged as the strongest predictor of peak leg vascular resistance (standardized coefcient 0.61, P , 0.0001), independent of age, peak VO2, creatinine, New York Heart Association class, and diuretic dose. This correlation between hyperuricaemia and post-ischaemic leg vascular resistance in cachectic patients with CHF indicates that the XO metabolic pathway may contribute to impaired vasodilator capacity in CHF. However, UA itself has potent antioxidant properties per se, 51 and acute urate infusions in healthy volunteers have not been shown to worsen endothelial function. Many proposals have been put forward to explain this paradox. Many of these have not been proved. Hayden and Tyagi52 proposed the antioxidant, pro-oxidant urate redox shuttle by which urate (under normal circumstances, a powerful antioxidant) becomes pro-oxidant in the atherosclerotic milieu of free radical generation from Fe2 and Cu2 ions leaked from atherosclerotic plaques and vasa vasorum rupture through the Fenton and Haber Weiss reactions. These free radicals, hydroxyl (OH2) and O2 in particular, uncouple 2 endothelial NO synthase and produce ONOO2. The idea that in a uid biological system at a particular concentration, urate switches from being an antioxidant to a pro-oxidant is intriguing but further data must be collected in order to conrm it. So the question then remains as to whether high UA levels represent a compensatory response of the body towards increased free radical production by XO or are merely a marker of XO activity.53

A clinical study41 revealed that there is an inverse relationship between serum UA concentration and measures of functional capacity in patients with HF. Fifty-nine patients with CHF due to coronary heart disease or dilated cardiomyopathy and 16 healthy control subjects made up the study population. Maximal oxygen uptake (MVO2) and regression slope relating minute ventilation to carbon dioxide output (VE-VCO2) were measured during a maximal treadmill exercise test. The metabolic assessment consisted of measuring serum UA, fasting lipids, and insulin sensitivity. Compared with healthy controls, patients with CHF had a 52% lower MVO2 (P , 0.001), 56.8% higher serum UA concentrations (P , 0.001), as well as a 60.5% lower insulin sensitivity (P , 0.001). In multivariate regression analysis, serum UA concentration emerged as a signicant predictor of MVO2 (r 20.50), exercise time (r 20.53) (both P , 0.001), VE-VCO2 slope (r 0.45), and NYHA functional class (r 0.36) (both P , 0.02), independent of diuretic dose, age, body mass index, serum creatinine, alcohol intake, plasma insulin levels, and insulin sensitivity index. This strong correlation between serum UA and MVO2the latter indicating an impairment in functional capacity following a reduction in cardiac outputsuggests that impaired oxidative metabolism plays an important role in the pathophysiology and generation of symptoms in HF. Chronic heart failure is associated with chronic inammation,42 as suggested by ndings of elevated levels of circulating cytokines,43 of their soluble receptors,44,45 and of soluble adhesion molecules.46 Serum UA is strongly related to circulating markers of inammation in patients with CHF,48 and XO-derived free radical release has been implicated in the increased expression of adhesion molecules by leucocytes,47 a prerequisite for leucocyte adhesion to vascular intima. So it is possible that the association between circulating UA and markers of chronic inammation reects the relationship between XO activity and leucocyte activation close to the vascular endothelium. Serum UA levels also parallel the chronic inammatory response which appears to occur with increasing severity of CHF.48 Anker et al.49 demonstrated that there is also a strong inverse relation between serum UA concentrations and maximum leg blood ow in patients with CHF. Twenty-two patients with CHF were included in their study. Lower limb blood ow was measured at rest and after maximum exercise followed by a 5 min period of ischaemia (maximum blood ow) using strain gauge venous occlusion plethysmography. All patients underwent metabolic assessment, which included measurements of serum UA. Patients in the upper tertile of serum UA had lower maximum blood ow than those in the lowest tertile [15.6 (2.2) vs. 31.0 (2.1) mL/100 mL/ min, P 0.003]. Serum UA correlated with maximum blood ow (r 20.86, P , 0.001), but not with resting blood ow. In stepwise regression analysis, UA emerged as the only predictor of maximum blood ow [standardized coefcient 20.83 (P , 0.001), R 2 0.68 (P , 0.001)], independently of diuretic dose, age, body mass index, plasma creatinine, fasting and IVGTT glucose and insulin, insulin sensitivity, maximum oxygen uptake and exercise time during the treadmill exercise test, and alcohol intake. This inverse correlation between serum UA and lower limb blood ow can be explained by the deleterious effects of XO-derived free radicals on vascular function. Oxygen free radicals seem to play an important role in the impairment of vasomotor

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Oxidative metabolism and prognosis in heart failure

Several factors are predictive of impaired survival in CHF. The three main areas of prognostic importance are haemodynamics, functional capacity, and metabolic factors, including neuroendocrine and immunological processes. Various studies have suggested that metabolic factors may be of greater importance than more conventional assessments of haemodynamic status and clinical features.54 56 Anker and Coats55 initially proposed a metabolic,

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Figure 3 Kaplan Meier survival plot for patients in the three HFSS subgroups, stratied by serum uric acid (cut-off 565 mmol/L). HFSS 1
indicates low-risk group; 2, medium-risk group; 3, high-risk group (reprinted from Anker et al.56)

functional, and haemodynamic (MFH) staging system for the assessment of prognosis in CHF. Such a system would depend on a straightforward metabolic marker. Anker et al.56 subsequently proposed that the metabolic marker could be serum UA levels, so they graded the relation between serum UA and survival. In separate studies, they validated the prognostic value of UA (n 182) and investigated the relationship between the decision to list a patient for heart transplantation (n 120) and the MHF score, a three-risk-factor model based on three parameters: a high UA level as marker of metabolic status (M), a marker of low functional capacity (peak VO2 14 mL/kg/min) (F), and a marker of poor cardiac function [left ventricular ejection fraction (LVEF) 25%] (H). In the derivation study, the best mortality-predicting UA cut-off (at 12 months) was 565 mmol/L (9.50 mg/dL) (independent of age, peak VO2, LVEF, diuretic dose, sodium, creatinine, and urea; P , 0.0001). In the validation study, UA 565 mmol/L predicted mortality (hazard ratio 7.14; P , 0.0001). In 16 patients (from both studies) with UA 565 mmol/L, LVEF 25%, and peak VO2 114 mL/kg per min (MFH score 3), 12 month survival was lowest (31%) compared with patients with two risk factors (64%), one (77%), or none (98%, P , 0.0001). In an independent study, 51% of patients with an MFH score of 2 and 81% of patients with an MHF score of 3 were listed for transplantation. The positive predictive value of not being listed for heart transplantation with an MHF score of 0 or 1 was 100% (Figure 3).

Relation between uric acid levels and diastolic dysfunction

Markers of diastolic dysfunction are frequently observed in patients with HF.57 Severe diastolic dysfunction is characterized by a

restrictive mitral lling pattern (RMFP) and is associated with the severity of symptoms,58 functional impairment,59 and adverse prognosis in patients with CHF.60 The diastolic abnormalities relate to elevated left ventricular lling pressures resulting from increased left ventricular chamber stiffness with consequent upward shift of the left ventricular pressurevolume loop.61 Myocardial diastolic properties are in part linked with histological myocardial changes resulting from increased collagen deposition62 and with the active process of isovolumetric relaxation of the myocardium.63 Our group64 evaluated the effects of elevated UA levels on cardiac function in 150 patients with CHF resulting from dilated cardiomyopathy of diverse aetiology. Patients underwent a complete echo-Doppler examination, with measurement of mitral E-wave and mitral A-wave velocities, E/A ratio, E-wave deceleration time (DtE), left ventricular volumes, ejection fraction, and stroke volume. An RMFP was dened as either E/A ratio .2 or E/A .1 and DtE ,140 ms. Twenty-four patients (16%) had an RFMP; these patients had signicantly higher UA levels compared with patients without RMFP (0.48 + 0.14 mmol/L vs. 0.38 + 0.08 mmol/L, respectively, P , 0.001). We found a signicant relationship between serum UA and parameters of diastolic function. Uric acid levels correlated signicantly with mitral E-wave velocity (r 0.22, P , 0.01), E/A ratio (r 0.21, P , 0.05), DtE (r 0.26, P , 0.01, and RMFP (P 0.0001) (Figure 4). On the other hand, urate levels did not correlate with markers of systolic function or with left ventricular volumes. In a multivariate model, UA predicted DtE independently of renal function, diuretic dose, and left ventricular volumes. These ndings might partly result from free radical-mediated endothelial injury with consequent reduction of NO production, which is known to regulate myocardial diastolic function: it has been reported that endogenous NO facilitates the

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after acute and chronic allopurinol therapy, since both treatments reduce UA plasma levels, only acute allopurinol treatment reduced left ventricular ROS determined using spin resonance spectroscopy. So these long-term effects were caused, at least in part, by a transient reduction of myocardial ROS shortly after initiation of allopurinol treatment, but it remains to be conrmed whether other mechanisms independent of myocardial redox status, such as reduced inammation, were involved. Assuming that dilated cardiomyopathy is characterized by an imbalance between left ventricular performance and myocardial energy consumption, Cappola et al.72 used intracoronary allopurinol to analyse the effects of XO inhibition on left ventricular function in nine patients with this disease. The patients were instrumented to assess myocardial oxygen consumption (MVO2), peak rate of rise in left ventricular pressure (dP/dtmax), stroke work (SW), and efciency (dP/dtmax/MVO2 and SW/MVO2) at baseline and after sequential infusions of intracoronary allopurinol (0.5, 1.0, and 1.5 mg/min, each for 15 min). Allopurinol caused a signicant decrease in MVO2 (peak effect 216 + 5%; P , 0.01; n 9), with no parallel decrease in dP/dtmax or SW and no change in ventricular load. The net result was a substantial improvement in myocardial efciency (peak effect: dP/dtmax/ MVO2, 22 + 9%, n 9; SW/MVO2, 40 + 17%, n 6; both P , 0.05), indicating that XO activity may contribute to abnormal energy metabolism in human cardiomyopathy. This suggested a potential therapeutic strategy for the treatment of this disease, involving reversal of the energy inefciency of the failing heart through pharmacological XO inhibition. Various studies73,74 have evaluated the effects of XO inhibition with allopurinol on endothelial function and peripheral blood owall have shown an improvement in peripheral vasodilator capacity and blood ow, both locally and systemically. Doehner et al.75 determined endothelium-dependent (acetylcholine infusion) and endothelium-independent (nitroglycerin infusion) vasodilation of the radial artery in 10 CHF patients with normal serum UA levels (315 + 42 mmol/L) and 9 patients with elevated UA (535 + 54 mmol/L). Co-infusion of allopurinol (600 mg/min) improved endothelium-dependent but not endothelium-independent vasodilation in hyperuricaemic patients (P , 0.05). In a double-blind crossover study, 14 hyperuricaemic (558 + 21, 455743 mmol/L) CHF patients were randomly allocated to allopurinol 300 mg/day or placebo for 1 week. Treatment reduced UA levels by .120 mmol/L in all patients (mean reduction 217 + 15 mmol/L, P , 0.0001). Compared with placebo, allopurinol improved peak blood ow (venous occlusion plethysmography) in the arms (24%, P 0.027) and legs (23%, P 0.029). Flow-dependent ow improved by 58% in the arms (P 0.011), and there was a direct relation between change in UA levels and improvement of owdependent ow after treatment (r 0.63, P , 0.05). A recent study76 showed that a steep doseresponse relationship exists between allopurinol and its effect on endothelial function as assessed by standard forearm venous occlusion plethysmography. Allopurinol 600 mg/day signicantly increased forearm blood ow response to acetylcholine compared with both allopurinol 300 mg/day and placebo [%change in forearm blood ow (mean + SEM): 240.31 + 38.19 vs. 152.10 + 18.21 vs. 73.96 + 10.29%, P , 0.001).

Figure 4 Linear relationship between serum uric acid levels

and mitral E-wave velocity (reprinted from Cicoira et al.,64 with the permission of Elsevier; licence number 2012441095848).

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Frank Starling response in the heart, probably by increasing diastolic distensibility.65

Xanthine oxidase inhibition studies

All of these data suggest a role for the XO metabolic pathway in the pathophysiology of CHF and other cardiovascular diseases. Blocking XO-generated oxygen radical accumulation has emerged as an intriguing new treatment option for preventing oxygen radical accumulation and its adverse effects. An increasing number of experimental and clinical studies have begun to test whether this therapeutic approach translates into meaningful benecial pathophysiological changes.66 68 In Engberdings study,69 mice with extensive anterior MI induced by permanent ligation of the left anterior descending coronary artery were randomized to treatment with either vehicle or the XO inhibitor allopurinol for 4 weeks, starting 1 day after the acute ischaemic event. Infarct size was similar in the two groups. Xanthine oxidase expression and activity, as determined by electron spin resonance spectroscopy, were found to be markedly increased in the remote myocardium of mice after MI. Myocardial ROS production was increased after MI but markedly reduced after allopurinol treatment. Allopurinol treatment substantially attenuated left ventricular cavity dilatation and dysfunction after MI, as assessed by echocardiography, and markedly reduced myocardial hypertrophy and interstitial brosis, demonstrating its novel benecial effect on left ventricular remodelling processes and left ventricular function which was probably mediated, at least in part, by reduced myocardial XO activity and ROS production. Analogous results occurred in a very recent study70 in a TO-2 hamster model of dilated cardiomyopathy, conrming the potential role of allopurinol as a benecial treatment for HF. Similarly, Mellin et al.71 compared the effects of a 5 day and 10 day treatment with allopurinol on haemodynamics and left ventricular function and structure in rats with established CHF induced by left coronary ligation. They found that long-term allopurinol treatment improved left ventricular haemodynamics and function and prevented left ventricular remodelling. Despite XO inhibition

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In a retrospective cohort study, Struthers et al.77 aimed to examine whether allopurinol treatment was associated with any alteration in mortality or hospitalization in patients with CHF, assuming that a high urate concentration is independently associated with mortality, with a four-fold increase in risk of death. They observed that long-term high-dose (.300 mg/day) allopurinol was associated with a signicantly better survival than longterm low-dose allopurinol (relative risk 0.59, 95% CI 0.370.95). High risk associated with a longstanding high urate concentration is adequately reduced only by long-term high-dose allopurinol. This may mean that high-dose allopurinol can fully negate the adverse effect of urate and improve survival. In a randomized, double-blind study78 of 60 CHF patients (NYHA IIIII), oxypurinol 600 mg/day or placebo was administered for 1 month in addition to standard therapy, and effects on LVEF, serum UA level, and 6 minute walking test were evaluated. Left ventricular ejection fraction improved in the active treatment group, but this increase was statistically signicant only when patients with LVEF .40% at baseline were excluded (increase of 6.8 + 2.8% from baseline to 1 month in the oxypurinol group relative to placebo, P , 0.02). No increase in walking capacity was detected. The authors suggest that these results may be related to the decrease in oxidative stress, in particular that after XO inhibition, less O2 production would lead to more NO availability and 2 a decrease in afterload, and myolament Ca2 responsiveness would recover towards normal and therefore improve myocardial contractility. They nally speculate that reverse remodelling as a consequence of a decrease in oxidative stress would also increase cardiac performance. Further to these positive ndings for XO inhibition, the OPT-CHF Study79 is the rst to evaluate clinical effects in unselected patients with moderate-to-severe HF. This very recent, multicentre, randomized, double-blind, placebo-controlled trial was designed to test whether XO inhibition with oxypurinol (600 mg/day) could produce clinical benets in patients (n 405) with systolic dysfunction and symptomatic HF treated with optimal HF therapies. Efcacy was assessed using a composite endpoint compromising HF morbidity, mortality, and quality of life. The percentage of patients characterized as improved, unchanged, or worsened did not differ between those receiving oxypurinol or placebo. Oxypurinol reduced serum UA by 2 mg/dL (P , 0.001). In a subgroup analysis, patients with elevated UA levels (.9.5 mg/dL, n 108) responded favourably to oxypurinol (P 0.02 for interaction term), whereas oxypurinol patients with UA levels ,9.5 mg/dL exhibited a trend towards worsening. In addition, reduction in serum UA levels by oxypurinol correlated with favourable clinical response. Within the entire oxypurinol patient cohort, those characterized as either improved or unchanged had signicantly greater reductions in serum UA levels compared with patients who worsened (22.3 + 2.1 vs. 21.0 + 1.9 mg/dL, P 0.0006). These results suggest that despite the fact that oxypurinol did not improve clinical outcome relative to patients randomized to placebo, benets occurred in patients with elevated serum UA levels in a manner which correlated with the degree of UA reduction. The UA ndings are consistent with reports from Anker et al.,56 indicating that UA is a valuable biomarker of morbidity and mortality in

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HF; and that HF patients with elevated serum UA may represent a valuable patient population responsive to therapy with XO inhibition.

Conclusions
In patients with CHF, hyperuricaemia is a common nding and is associated with the impairment of peripheral blood ow and reduced vasodilator capacity, which relate closely to clinical status and reduced exercise capacity. It has been proposed that the link between hyperuricaemia and worse clinical status in patients with CHF might be mediated by an increase in oxidative stress, in particular in elevated XO expression and consequent increased production of oxygen free radicals. Growing evidence shows that this impaired oxidative metabolism due to enhanced ROS release is implicated in the development of cardiac hypertrophy, myocardial brosis, left ventricular remodelling, and contractility impairment responsible for worsening of cardiac function in CHF. Recent ndings also suggest an association between UA levels and parameters of diastolic function; more importantly, UA has emerged as a strong independent prognostic factor in patients with CHF. The aforementioned studies outline the potential benets of XO inhibition in CHF patients. Allopurinol improves myocardial energy and endothelial dysfunction and vasodilator reactivity to exercise by reducing markers of oxidative stress responsible for vascular dysfunction. Oxypurinol increases LVEF when depressed at baseline, and as recently shown in the OPT-CHF Study, improves clinical outcome in CHF patients presenting with high serum UA levels. In this context, XO inhibition may represent a novel option in the treatment of CHF subgroups, an intriguing therapeutic possibility which remains to be conrmed by further studies. Conict of interest: none declared.

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