Elevated plasma β-hydroxybutyrate predicts adverse outcomes and disease progression in patients with arrhythmogenic cardiomyopathy

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Science Translational Medicine  12 Feb 2020:
Vol. 12, Issue 530, eaay8329
DOI: 10.1126/scitranslmed.aay8329

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Insight from metabolites

Some individuals with arrhythmogenic cardiomyopathy (AC) can live for decades without symptoms, and reliable and specific markers of disease progression remain lacking. Song and colleagues studied metabolic markers in the plasma and hearts of individuals with AC and their relatives. They found elevated plasma ketones, specifically β-hydroxybutyrate, in affected individuals and relatives suspected of having AC. Metabolomics using patient cells and a mouse model of the disease revealed that cardiomyocytes exhibited de novo ketogenesis with higher fatty acid oxidation that favored medium-chain fatty acid substrates. Individuals with early AC with major adverse cardiac events had elevated plasma β-hydroxybutyrate, suggesting that this may be a useful marker of disease progression.


Sudden death could be the first symptom of patients with arrhythmogenic cardiomyopathy (AC), a disease for which clinical indicators predicting adverse progression remain lacking. Recent findings suggest that metabolic dysregulation is present in AC. We performed this study to identify metabolic indicators that predicted major adverse cardiac events (MACEs) in patients with AC and their relatives. Comparing explanted hearts from patients with AC and healthy donors, we identified deregulated metabolic pathways using quantitative proteomics. Right ventricles (RVs) from patients with AC displayed elevated ketone metabolic enzymes, OXCT1 and HMGCS2, suggesting higher ketone metabolism in AC RVs. Analysis of matched coronary artery and sinus plasma suggested potential ketone body synthesis at early-stage AC, which was validated using patient-derived induced pluripotent stem cell–derived cardiomyocytes (iPSC-CMs) in vitro. Targeted metabolomics analysis in RVs from end-stage AC revealed a “burned-out” state, with predominant medium-chain fatty acid rather than ketone body utilization. In an independent validation cohort, 65 probands with mostly non–heart failure manifestations of AC had higher plasma β-hydroxybutyrate (β-OHB) than 62 healthy volunteers (P < 0.001). Probands with AC with MACE had higher β-OHB than those without MACE (P < 0.001). Among 94 relatives of probands, higher plasma β-OHB distinguished 25 relatives having suspected AC from nonaffected relatives. This study demonstrates that elevated plasma β-OHB predicts MACE in probands and disease progression in patients with AC and their clinically asymptomatic relatives.

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