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 Diabetic cardiomyopathy: does it exist ?
New insights with Apolipoprotein O: Upregulated in human diabetic
heart and promotes mitochondrial dysfunction and lipotoxicity.
Dr Fatima SMIH 
TEAM  7: « Obesity and heart failure: molecular and clinical investigations » 
I2MC INSERM UMR 1048
 1 Avenue Jean Poulhes BP 84225 31432 Toulouse cedex 4. France 
http://www.i2mc.inserm.fr.
 
Global Projections for the diabetes epidemic: 2010–2030 =>  Impact on HEART ?
World
2010 = 285 million
2030 = 439 million
Increase 54%
Lei Chen et al.
Nature Reviews Endocrinology, 2012
METABOLIC or DIABETIC
CARDIOMYOPATHY
Diabetic cardiomyopathy, 
a consequence of metabolic disorders.
Nutritional/Metabolic
disorders
(Obesity, diabetes…)
Left Ventricular 
HYPERTROPH
Y
ventricular
DILATATION 
FIBROSIS
Metabolic Switch
to Fat Consumption
LIPOTOXICITY.
STRUCTURAL
 CHANGES
Enlarged 
septum
FONCTIONAL 
CHANGES
Loss of
cardiac cells
DIASTOLIC 
dysfunction
SYSTOLIC 
dysfunction
Zhou, Yan-Ting et al. (2000)
 Proc. Natl. Acad. Sci. USA 97, 1784-1789
Accumulation of lipid droplets in the myocardium of diabetic rat
18 week-old fa/fa diabetic / obese rats’ myocardium
Lipids
droplets
A hallmark of the diabetic cardiomyopathy ? 
Accumulation of lipids occurs also in the diabetic Accumulation of lipids occurs also in the diabetic 
failing human heartfailing human heart
Sharma et al., Sharma et al., FASEB JFASEB J. 2004. 2004
HF + Diabetic HF + Obese HF 
Analysis of Heart Molecular Adaptation to Obesity: 
Functional Genomics for Dog Heart Transcriptome  
Obese dogs
Weight : 14,5 à 17, 5 kg
Control dogs
Weight : 12 à 14,5 kg
Os = O - N Ns = N - O
RT-PCR (SMART)
Common
sequences
Obese
hypertensive
Control
Suppressive Substractive Hybridization
Enrichment for differentially expressed genes
Ligation
In plasmid
Transformation
RNA extraction
RNA from
Obese hypertensive RNA from control heart
Bacterial Amplification
9 weeks HFD
Numerical autoradiography (Storm 860®)
Computer analysis
 X-Dot Reader software (COSE) Microarrays analysis of differential expression
Obese hypertensive control
Organized cDNA Bank
(2400 clones)PCR
Spotting
(4800 spots)
Differential hybridization
Obese target
Differential hybridization
Control Target
PCR
DNA sequencing
(~200 differentially expressed sequences
Real-time PCR expression verification
Cloning of the human homolog cDNA
Search for homology in DNA sequence database
cDNA Libray enriched
for overexpressed genes
cDNA Libray enriched
for downregulated genes
Hormones
ENERGETICMETABOLISM
Prolifération
IONICFLUX
Remodeling
Discovery of 11 genes
Encoding for unknown
Proteins:
1) Apolipoprotein
2) Transcription factor
Philip-Couderc et al.,Hypertension 2003
Discovery of a new apolipoprotein: APOO
obese heart Control heart Cloning of the human ortholog
« New » protein:
(Philip-Couderc P., Hypertension, 2003)
Differential expression in the 
obese heart
9 weeks HFD
cDNA SEQUENCING
11 genes with 
unknown function
We named : APOO 
- Secreted protein
- Apolipoproteins’ family
APOO polypeptidic sequence is conserved within species.
Lamant, J. Biol. Chem, 2006
APOO (22 kDa)
 helix Antibodies
Against two specific
peptides
COOHNH2
APOO Characterization.
APOO Characterization.
Lamant, J. Biol. Chem, 2006
Ø Associated with lipoproteins.
     Mainly detected in HDL.
(High Density Lipoproteins)
Can associate with lipids.
Can form lipoproteins.
ApoO
Discoidal
particle
Lipids
In vitro
APOO is overexpressed in human diabetic heart
(Lamant, J. Biol. Chem, 2006)
Ø Up-regulated in diabetic hearts.
What is the role of 
cardiac APOO 
overexpression?
Diabetic transgenic mice 
Overexpressing APOB in heart
Reduced  Lipid stores in heartLipid stores in heart
Reduced Apoptosis
Improved cardiac functionImproved cardiac function
Nielsen et al, JBC (2002)
Protection from « Lipoapoptosis »Protection from « Lipoapoptosis »
Physiological Overexpression of APOO in Cardiac 
Specific Transgenic Mice.
A  model of diabetic cardiomyopathy ?
hAPOO cds
MHC promoter
WT
    APOO
CALR
APOO-Tg
WT APOO-Tg
0
4
8
12 ***
APOOmRNA(A.U.)
WT APOO-Tg
0
20
40
60
*
PRinterval(ms)
WT APOO-Tg
Depressed heart function
On the contrary to APOB, APOO overexpression in heart is not protective.
High Fat Diet
Turkieh et al. The Journal of Clinical Investigation, 2014
0 0.2 0.4 0.6 0.8 0 0.2 0.4 0.6 0.8
WT APOO-Tg
0
0.5
1.0
1.5
2.0
**
Cd36mRNA(A.U.)
0
1
2
3
4
Fatp4mRNA(A.U.)
*
0
2
4
6
Acsl3mRNA(A.U.)
*
0
10
20
30
40
*
Palmitoyl-CoAx104
(nmol/min/mgprotein)0
2
4
6
8
10
r = 0.7415 P < 0.0001
APOO mRNA (A.U.)
ACSL3mRNA(A.U.)
0
3
6
9
12
r = 0.5853 P = 0.0004
FATP4mRNA(A.U.)
APOO mRNA (A.U.)
0 0.2 0.4 0.6 0.8
0
3
6
9
12
r = 0.5422 P = 0.0024
CD36mRNA(A.U.)
APOO mRNA (A.U.)
Mouse heart
Human heart
APOO induces fatty acid metabolism
in mouse and human heart
0
3
6
9
12
15
18
CD36expression(A.U.)
Low APOO
expression
High APOO
expression
***
0
50
100
150
200
FATP2expression(A.U.)
Low APOO
expression
High APOO
expression
*
Data mining on 107 human heart
microarrays from GEO database
APOO induces fatty acids metabolism
TEM of myocardial sections of mouse heart after HFD.
WT APOO-Tg
x10,000 x15,000
APOO overexpression induces myocardium
disorganization and mitochondrial swelling
-3.0 -2.5 -2.0 -1.5 -1.0 -0.5 0.5 1.0 1.5 2.0 2.5 3.0 3.5
-2.0
-1.5
-1.0
-0.5
0.5
1.0
1.5
2.0Oxydative phosphorylation
Mitochondrial dysfunction
P < 0.0001
r = 0.7621 P < 0.0001
r = 0.7757
Mean APOO
expression (A.U.)
Meangenes
expression(A.U.)
NDUFA2
NDUFA3
NDUFA6
NDUFA8
NDUFAB1
NDUFB10
NDUFB11
NDUFB2
NDUFB5
NDUFB8
NDUFS2
NDUFS4
NDUFS7
NDUFV1
NDUFV3
SDHA
SDHB
SDHC
SDHD
UQCRB
UQCRC2
UQCRFS1
UQCRH
CYC1
CYCS
COX11
COX15
COX17
COX4I2
COX5B
COX6A2
COX7A2
COX7A2L
COX7C
ATP5C1
ATP5J
0
2
4
6
8
10
12
14
16
18
20
22
C I C II C III C IV C V
Meanexpressionlevel(A.U.)
Low APOO
High APOO
Data mining on 107 human heart
microarrays from GEO database
Cardiac myoblasts cell lines overexpressing APOO
+ cDNA APOO
A1/A4/E domain
1981
N-
40 83
-C
WT APOO
H9c2 cardiomyoblasts
Expression vectors  APOO
Control
Cont. APOO
0
5
10
15
*
FAMEx100
(nmol/mgprotein)
APOO overexpression promotes lipid overload in cardiac myoblasts
= APOO Cells
CAPOO
Mit.
CAPOO
Recom.
APOO
   APOO
ANT
Cyto. 
APOO
Green MitotrackerAPOO/TMR stain Merge
 
 
APOO
Recom.
APOO
Membranes 
APOO C
CALR.
What is APOO localization in cardiac myoblasts?
APOO Overexpression
APOO:
Fluorescent
labelling
Subcellular 
protein 
fractionation
Recom.
APOO D 1-40 Cyto. Mit.
APOO 
D 1-40
ANT
ACTIN
APOO D1-40
Green MitotrackerAPOO/TMR stain Merge
APOO localizes to the mitochondria in cardiac cells
APOO D1-40 Overexpression in cardiac myoblasts
APOO D1-40:
Fluorescent 
labelling
A1/A4/E domain
198
N-
40 83
-C ApoO Δ1-40
1
Mutated 
APOO
Deletion of the mitochondrial adress label
Subcellular 
protein 
fractionation
Control
shRNA APOO
APOOD 1-40
APOO
O2Flow
(pmol/s/106
cells)
 
0
25
50
75
100
*
**
Cont.
0
1
2
3
4
5
Cyt.Coxyd.activity
(µmol/min/µgprotein)
***
APOO
0
500
1,000
1,500
2,000
2,500 Control
ApoO
DCFDA (µM)
DCFfluo/10
6
cells
0 1 2 3 4 5 6
0.0
0.1
0.2
0.3
Cyt.Coxyd.activity
(µmol/min/µgprot.)
APOO-TgWT
*
A role for APOO in mitochondrial function?
APOO enhances mitochondrial respiration
and oxidative stress in cardiac myoblast.
0
2
4
6
8
**
***
Cd36mRNA(A.U.)0
4
8
12
16
***
*
Fatp4mRNA(A.U.)
0
2
4
6
8
10 ***
*
***
Nadhdh
mRNA(A.U.)
0
2
4
6
8 ***
**
**
Ndufa7
mRNA(A.U.)
A role for APOO in mitochondrial function?
Oxidative
Phosphorylation
genes
Fatty acids
transporters
genes
Control
shRNA APOO
APOOD 1-40
APOO
0
10
20
30
40 ***
Palmitate
**
Diglycerides
(nmol/mgprotein)
Mouse heartCardiac myoblasts
APOO
Control
APOO D1-40
WT APOO-Tg
0
2
4
6
Diglycerides
(nmol/mgprotein)
**
WT APOO-Tg
0
5
10
15
20
Triglycerides
(nmol/mgprotein)
Palmitate
0
10
20
30
40
 Triglycerides 
(nmol/mg protein)
0 0.2 0.4 0.6
0
2
4
6
8 r = 0.6389 P = 0.0002
APOO mRNA (A.U.)
Diglycerides
(nmol/mgprotein)
Human heart
0
100
200
300 r = 0.0331 P = 0.8978
APOO mRNA (A.U.)
Triglycerides
(nmol/mgprotein)
0 0.2 0.4 0.6 0.8
APOO induces lipotoxicity
What happens when lipid uptake exceeds
mitochondrial oxidative capacity?
0
2
4
6
8
10
12
*
***
BaxmRNA(A.U.)
APOOCont. shAPOO
Cardiac myoblasts
shAPOO
0
10
20
30
**
***
Caspase3activityx10
(RFU/µgprotein)
APOOCont.2
0 125 250 500
0
100
200
300
400
500
**
***
***
Caspase-3activityx1O
2
(RFU/µgprotein)
*
Palmitate
Control
APOO
Human heart
0.2 0.4 0.6 0.8
0
0.1
0.2
0.3 r = 0.7289
p < 0.0001
BAXmRNA(A.U.)
APOO mRNA (A.U.)
Mouse heart
0
5
10
15
***
Caspase3activityx1O
RFU/µgprotein
APOO-TgWT
2
WT
Bax/Bcl-2mRNA(A.U.)
APOO-Tg
Is APOO inducing lipoapoptosis?
APOO induces apoptosis
• PPAR is a transcription factor involved in lipid uptake.
• Ppara overexpression in mice led to cardiac dysfunction.
• The expression and activity of PPAR increase in diabetic
hearts.
• The increase in intracellular lipid content in APOO models,
should be associated with an induction of the expression of
PPAR
Are APOO models mimicking diabetic cardiomyopathy?
Finck BN, et al. J Clin Invest. 2002
APOO associates with an increase in Ppar  expression.
Cont.APOO
0
2
4
6
8
10
12
PparamRNA(A.U.)
*
P-AMPK 
CALR 
AMPK 
Cont. APOO
Mouse heart
5 10 15 20 25
0
2
4
6
8 r = 0.81 P < 0.0001
Apoo mRNA (A.U.)
PparamRNA(A.U.)
0 0.2 0.4 0.6 0.8
0
0.1
0.2
0.3
0.4
0.5 r= 0.48
PPARAmRNA(A.U.)
P = 0.0006
APOO mRNA (A.U.)
0
Human heart
Cardiac myoblasts
• PGC-1 , a master regulator of mitochondrial biogenesis, is
upregulated in diabetic heart
• Ultrastructural analyses have revealed mitochondrial damage
in mouse models of the metabolic syndrome and in models of
type 1 and type 2 diabetes.
Are APOO models mimicking diabetic cardiomyopathy?
Handschin C. et al. Endocr. Rev. 2006
Mitochondrial degradation in APOO cells
0 5 10 15 20 25
0
2
4
6
8
r = 0.81 P < 0.0001
Apoo mRNA (A.U.)
Pgc1amRNA(A.U.)
Mouse heart
Human heart
0 0.2 0.4 0.6 0.8
2
4
6
8
10
12 r= 0.63 P = 0.0002
mRNA(A.U.)PGC-1A
APOO mRNA (A.U.)
nM
nM
nM
N
Control +100µM palmitate
aM
mf
mF
N
APOO + 100µM palmitate
mf
mF
0.0
0.5
1.0
1.5
2.0
2.5
***
ATP/AMPratio
Cont. APOO
PPARPPAR
Multilamellar 
bodies
ROS
FATPs
LCFAs
NADH
FADH2
Metabolic 
sink
b-Oxid.
Plasma 
membrane
1
2
4
3
Lipotoxic 
byproducts
5
DNA
PGC1
PPAR
Nucleus
6
Oxidative
Phospho.
Cytoc.C
Cell death
BAX
Apoptosome
7
IMM
OMM
APOO
Conclusion: The pathological overexpression of APOO induces
a mitochondrial metabolic sink
APOO overexpression drives the cell into a vicious cycle consisting of 
a cascade of maladaptive events that ends in apoptosis and cell death 
mimicking the diabetic cardiomyopathy. 
Turkieh et al. The Journal of Clinical Investigation, 2014
INSERM UMR 1048 Team 7
Toulouse University Hospital
Dr Philippe Rouet, PhD
Prof. Galinier, MD-PhD
Prof. C. Dambrin, MD-PhD
Dr P. Massabuau, MD
Dr M.Berry, MD
M. Barutaut
M. F. Evaristi
Dr C. Caubère,
Dr A. Turkieh,
Dr. V. Le Berre, PhD
Dr S. Sokol, PhD
L. Trouilh
Toulouse Genopole and Genotoul Network
Cardiology Federation
Acknowledgments
0
5
10
15
20
25
30 ***
***
Palm. 100 µM
-
+ -+
+
-
Oleate 10 µM -
Diglycerides
(nmol/mgproteins)
+
***
0
0.25
0.50
0.75
1.00
1.25
Palm. 100 µM
-
+-+
+
-
Oleate 10 µM - +
***
***
***
DG/TG
0
25
50
75
100
Palm. 100 µM
-
- + +
-
-
-
-
+
+
+
-
-
-
-
+
+
-Oleate 10 µM
Oleate 1 µM
***
***
Caspase-3activityx10
2
(RFU/µgproteins)
APOOCont. shAPOO
0
2
4
6
8
10
12
**
***
Fatp4mRNA(A.U.)
0
5
10
15
20
25
***
***
***
Triacsin C
***
Palmitoyl-CoAx104
(nmol/min/mgprotein)
APOOCont. shAPOO
0
2
4
6
8
10
***
***
Cd36mRNA(A.U.)

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