Does Pharmacological Exercise Mimetics Exist?

Hokkaido University Graduate School of Medicine

Shintaro Kinugawa

100

0

50

25

0

9 15

75

3 6 12

Su

rviv

al

rate

(%

)

Follow up (Months)

Peak Oxygen Uptake (VO2)

（mL/kg/min） >18

>14 ≦18 >10 ≦14

≦10＊

Peak oxygen uptake and prognosis in patients with heart failure (HF)

Mancini DM, et al. Circulation 1991; 83: 778-786

Factors regulating exercise capacity

VCO2

VO2

Lung Heart

Blood

Pulmonary circulation Peripheral circulation

Skeletal muscle

Mitochondria Expiration

Inspiration

O2 transport

CO2 transport

CO2 production

O2 consumption

Reserve capacity

Large Small

0

1

2

3

4

5

Rest Submax Max

*

*

Control Dobutamine

0

20

40

60

80

100

Rest Submax Max

*

* *

Rest Submax Max

0

500

Rest Submax Max

1000

0

10

20

30

40

50

Wilson JR, et al. Am J Cardiol. 1984; 53: 1308-15

Dobutamine does not increase exercise capacity

Leg

blo

od

flo

w (

L/m

in)

O2 e

xtr

act

ion

(%

)

VO

2 (

mL

/min

)

La

ctate

(m

g/d

L)

Morphology Histology Biochemistry Others

Muscle wasting

Muscle fiber atrophy

（IIb）

Type I fibers

Type II fibers

Shift from type IIa to

IIb

Oxidative enzymes

Glycolytic enzymes

Impaired energy

metabolism

Ergoreflex

Capillary density Shift from MHC1 to

MHC2

Mitochondrial volume eNOS

Apoptosis

Skeletal muscle abnormalities in HF

Okita K, et al. Circ J 2013; 77: 293-300

Skeletal muscle abnormalities are largely associated with the limited exercise

capacity in patients with HF and are the target of exercise therapy.

Modified, Piepoli MF. BMJ 2004; 328: 189

Su

rviv

al

rate

(%

)

Follow up (days)

70

80

90

100

0 100 200 300 400 500 600 700

Training

Control

Aerobic exercise training improves survival rate

in patients with HF

(ExTraMATCH)

1. Improve exercise capacity (peak VO2, AT)

2. Minor change in cardiac function (LV systolic function and

remodeling)

3. Improve endothelial function (Coronary and peripheral

circulation)

4. Improve ventilation

5. Improve autonomic nerves function

6. Improve skeletal muscle abnormalities

Effects of exercise therapy for heart failure

The greatest effect is to improve skeletal

muscle abnormalities.

Treatment targeting skeletal muscle abnormalities

Skeletal muscle abnormalities play an important role in the

pathogenesis of HF. However, no therapy targeting skeletal

muscle abnormalities has been developed. Developing new drug

therapy may be useful for treatment of patients with severe HF

who can’t perform aerobic exercise.

We focused on myokine secreted from skeletal muscle and

performed studies.

Pedersen BK, et al. Nat Rev Endocrinol 2012; 8: 457-65

Skeletal muscle is a huge endocrine organ

Control Caffeine

kDa

30

25

20

15

10

Mass

spectrometry

MWM

40

60

80 100 150

C2C12 myotubes

（mouse skeletal muscle）

Medium

Caffeine

（skeletal muscle

contraction）

Silver stain MW

Cultured medium

Without caffeine With caffeine

Name Cover

(%)

MASCOT

score Name

Cover

(%)

MASCOT

score

MIF 21 317 MIF 21 115

VEGF 6 38 VEGF 14 89

SPARC 5 36 BDNF 8 71

FSTL 3 44 FSTL 3 30

Search for proteins secreted by skeletal muscle contraction

BD

NF

/to

tal p

rote

in

(Ra

tio

to

ga

str

o)

BDNF

Gastro Soleus

0

0.5

1

1.5

2

Gastro Soleus

CBB

staining

SDH

* * *

Type II Type I

* *

* * *

* *

BDNF

Type I Type II

BDNF

Soleus

Gastrocnemius

*

BDNF is preferentially present in the slow twitch fiber

AMP

ATP

Transcription

Nucleus

β-oxidation

β-HAD

Mitochondrion TCA cycle NADH

FADH2

ATP

CO2

NAD+

FAD

ADP+Pi

Acetyl-CoA

CaMKK

CaMK

PGC1α

AMPKα SIRT1

SIRT3

NAD+

NADH

ROS

NO

p38MAPK

ATP

Electron transport chain

I II III IV

V

Cyt c

F0

F1

H+ H+ H+ ADP

+Pi

NA

DH

N

AD

+

Intermembrane

space

Matrix

Signal regulating mitochondrial biogenesis

Kinugawa et al. Int Heart J 2015; 56:475-84

TrKBR

BDNF rhBDNF BDNF KO mice

Work

(J)

0

5

10

15

20

25

30

35

SED+

vehicle

SED+

rhBDNF

ET+

vehicle

* *

Peak

VO

2 (

mL

/kg/m

in)

100

110

120

130

140

150

160

170

180

SED+

vehicle

SED+

rhBDNF

ET+

vehicle

* *

Ru

n d

ista

nce (

m)

Ru

n t

ime

(sec

)

0

100

200

300

400

500

600

700

800

SED+

vehicle

SED+

rhBDNF

ET+

vehicle

* *

0

500

1000

1500

2000

2500

SED+

vehicle

SED+

rhBDNF

ET+

vehicle

* *

BDNF mimics exercise training

rhBDNF + =

What a wonderful thing if this happen!!

p-AMPK

AMPK

0.0

0.5

1.0

1.5

2.0

SED+

vehicle

SED+

rhBDNF

ET+

vehicle

mtD

NA

(Ra

tio

to

SE

D+

veh

icle

)

P-A

MP

K/A

MP

K

* *

PGC-1

GAPDH

0.0

0.1

0.2

0.3

0.4

SED+

vehicle

SED+

rhBDNF

ET+

vehicle

PG

C-1

/GA

PD

H

*

0.0

0.1

0.2

0.3

0.4

SED+

vehicle

SED+

rhBDNF

ET+

vehicle

* *

*

Signaling regulating mitochondrial function

rhBDNF

p-AMPK Mitochondrial

function

Exercise

capacity

Exercise Training

BDNF

0

50

100

150

200

250

WT BDNF KOBDNF KO

+AICAR

CS

acti

vit

y

(mM

/min

/mg p

rote

in)

BDNF

GAPDH

P-AMPK

AMPK

BD

NF

/GA

PD

H

P-A

MP

K/A

MP

K

0.0

0.2

0.4

0.6

0.8

1.0

WT BDNF KOBDNF KO

+AICAR

†

0.0

0.2

0.4

0.6

0.8

1.0

WT BDNF KOBDNF KO

+AICAR

* * *

†

*

Pea

k V

O2,

mL

/kg

/min

Wo

rk,

J

100

120

140

160

180

WT BDNF KOBDNF KO

+AICAR

0

10

20

30

WT BDNF KOBDNF KO

+AICAR

†

* †

*

Effects of AMPK activator in BDNF KO mice

BDNF KO mice

p-AMPK

AICAR（AMPK activator） ＋

Mitochondrial

function

Exercise

capacity

0

0.2

0.4

0.6

0.8

1

1.2

Sham+vehicle

MI+vehicle

MI+rhBDNF

Sham+

vehicle

MI+

vehicle

BDNF

GAPDH

MI+

rhBDN

F

BD

NF

/GA

PD

H †

*

0

2

4

6

8

10

12

Sham+vehicle

MI+vehicle

MI+rhBDNF

Ser

um

BD

NF

(ng

/ml)

n.d. n.d.

BDNF expression is decreased in the skeletal muscle from

mice with HF after myocardial infarction

4wk

Intervention

Sham

MI

Sham+vehicle

MI+vehicle

MI+rhBDNF

Ope 2wk

Observation

Matsumoto J, et al. Circulation 2018; 138:2064-6

0

20

40

60

80

100

120

140

160

180

Sham+vehicle

MI+vehicle

MI+rhBDNF

Ph

ysi

cal

acti

vit

y (

cou

nt/

day

)

0

5

10

15

20

25

30

35

Sham+vehicle

MI+vehicle

MI+rhBDNF

0

5

10

15

20

25

30

Sham+vehicle

MI+vehicle

MI+rhBDNF

0

100

200

300

400

500

600

Sham+vehicle

MI+vehicle

MI+rhBDNF

* * †

*

* †

* * †

* †

0

1000

2000

3000

4000

5000

6000

Sham+vehicle

MI+vehicle

MI+rhBDNF

NS

Tota

l w

ork

(J)

Pea

k V

O2 (m

L/k

g/m

in)

To

tal

run

nin

g t

ime

(min

)

Tota

l ru

nnin

g d

ista

nce

(m

)

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

Sham+vehicle

MI+vehicle

MI+rhBDNF

Lac

tate

/wo

rk (

mm

ol/

L/J

) *

†

BDNF improves exercise capacity in HF mice

Matsumoto J, et al. Circulation 2018; 138:2064-6

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Sham+vehicle

MI+vehicle

MI+rhBDNF

pA

MP

Kα/AMPKα

*

†

PGC1α

/GA

PD

H

0

0.2

0.4

0.6

0.8

1

1.2

Sham+vehicle

MI+vehicle

MI+rhBDNF

*

† Sham+ vehicle

MI+ vehicle

MI+ rhBDNF

pAMPKα

PGC1α

GAPDH

AMPKα

BDNF activates AMPKα-PGC1α signal

in the skeletal muscle

0.0

0.2

0.4

0.6

0.8

1.0

1.2

CILeak

CIOXPHOS

CI+IIOXPHOS

CI+IIETS

CIIETS

Sham+vehicle

MI+vehicle

MI+rhBDNF

* * *

†

*

†

†

*

O2 f

lux

(rat

io t

o C

I+II

ET

SS

ham

+veh

icle)

P=0.08

P=0.13

BDNF improves mitochondrial respiration

in the skeletal muscle

Matsumoto J, et al. Circulation 2018; 138:2064-6

30

40

20

10

0

Peak VO2 (mL/kg/min)

0

r=0.53, P<0.001

10 20 30 40 50

Fukushima A, et al. Int J Cardiol 2013; 168: e142-4

40

30

20

10

0

P<0.001

Ser

um

BD

NF

(n

g/m

L)

Control HF

Ser

um

BD

NF

(n

g/m

L)

Control

HF

BDNF and exercise capacity in patients with HF

Fukushima A, et al. J Cardiac Fail 2015; 21: 300-6

0

0.2

0.4

0.6

0.8

1.0

0 5 10 15 20 25 30

BDNF≧17.4 ng/mL

(n=37)

BDNF＜17.4 ng/mL

(n=21)

Log-rank test

P=0.001

Ev

ent-

free

rate

Months

BDNF is an independent predictor for clinical events

Conclusion

BDNF may be a new treatment aiming

at improvement in exercise capacity and

targeting skeletal muscle.