Although two-thirds of cases of heart failure in the United

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1 Pharmacological Inhibition of -Protein Kinase C Attenuates Cardiac Fibrosis and Dysfunction in Hypertension-Induced Heart Failure Koichi Inagaki, Tomoyoshi Koyanagi, Natalia C. Berry, Lihan Sun, Daria Mochly-Rosen Downloaded from by guest on July 3, 218 AbstractStudies on genetically manipulated mice suggest a role for -protein kinase C ( PKC) in cardiac hypertrophy and in heart failure. The potential clinical relevance of these findings was tested here using a pharmacological inhibitor of PKC activity during the progression to heart failure in hypertensive Dahl rats. Dahl rats, fed an 8% high-salt diet from the age of 6 weeks, exhibited compensatory cardiac hypertrophy by 11 weeks, followed by heart failure at 17 weeks and death by the age of 2 weeks (123 3 days). Sustained treatment between weeks 11 and 17 with the selective PKC inhibitor V1-2 or with an angiotensin II receptor blocker olmesartan prolonged animal survival by 5 weeks ( V1-2: days; olmesartan: days). These treatments resulted in improved fractional shortening ( V1-2: 58 2%; olmesartan: 53 2%; saline: 41 6%) and decreased cardiac parenchymal fibrosis when measured at 17 weeks without lowering blood pressure at any time during the treatment. Combined treatment with V1-2, together with olmesartan, prolonged animal survival by 5 weeks (37 days) relative to olmesartan alone (from 16 5 to days, respectively) and by 11 weeks (74 days) on average relative to saline-treated animals, suggesting that the pathway inhibited by PKC inhibition is not identical to the olmesartan-induced effect. These data suggest that an PKC-selective inhibitor such as V1-2 may have a potential in augmenting current therapeutic strategies for the treatment of heart failure in humans. (Hypertension. 28;51:1-2.) Key Words: heart failure protein kinase C ventricular remodeling hypertrophy fibrosis Although two-thirds of cases of heart failure in the United States are because of myocardial infarction, hypertension is a major contributor to this morbidity. Therefore, we studied hypertension-induced heart failure using hypertensive salt-sensitive Dahl rats. 1,2 Because many of the signaling events associated with heart failure involve activation of protein kinase C (PKC), 1,3 we determined whether PKC regulation affects disease progression. We focused on PKC, because there are conflicting reports on its role in cardiac hypertrophy and heart failure based on genetic manipulation of mice. 1,4 6 Because the enzyme may have different roles during heart development, we used a pharmacological approach to selectively inhibit it at a defined time during disease. We previously designed isozyme-selective peptide regulators of PKC, which function by inhibiting or activating PKC translocation. These peptide regulators are linked to membrane-permeable peptides, TAT 47 57, to enable their effective intracellular delivery and are, therefore, useful pharmacological tools. Using the Dahl salt-sensitive hypertension-induced heart failure rat model, 1,2 we determined here whether sustained pharmacological inhibition of PKC with the abovementioned peptide or with an angiotensin receptor blocker, olmesartan, delays progression to heart failure. Methods Hypertension-Induced Heart Failure Model Animal protocols were approved by the Stanford University Institutional Animal Care and Use Committee. Male Dahl salt-sensitive rats on an 8% NaCl-containing diet or on a low-salt diet, as described previously, 1,4 6 were treated between the ages of 11 and 17 weeks with V1-2 or V1-1 (3 mg/kg per day), with equimolar concentrations of TAT (1.6 mg/kg per day; synthesized as described 4,7 ) or with saline, using osmotic pumps implanted subcutaneously (3 mg/kg per day provides a maximal effect on PKC translocation without causing any adverse effects 7 ). A fourth group was treated with olmesartan (3 mg/kg per day in.5% carboxymethylcellulose) by daily gavage (Figure S1A, available online at The osmotic pumps were replaced every 2 weeks but were discontinued after the age of 17 weeks, because half of the hypertensive control rats died by that age. Additional groups were treated with both V1-2 and olmesartan or with olmesartan alone from 11 to 19 weeks of age (Figure S1B). Cardiac functions and blood pressure did not differ between these groups before drug treatment (Figure S1C and S1D). Systolic blood pressure was measured by the tail-cuff method (BP-2, Visitech Systems), and fractional shortening (FS) was measured by transthoracic echocardiography (Vivid 7, GE). Left Received January 7, 28; first decision January 23, 28; revision accepted March 21, 28. From the Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, Calif. Current address (K.I.): Otsu Red-Cross Hospital, Shiga, Japan. The first 2 authors contributed equally to this study. Correspondence to Daria Mochly-Rosen, Department of Chemical and Systems Biology, Stanford University School of Medicine, CCSR, Room 3145A, 269 Campus Dr, Stanford, CA mochly@stanford.edu 28 American Heart Association, Inc. Hypertension is available at DOI: /HYPERTENSIONAHA

2 2 Hypertension June 28 Downloaded from by guest on July 3, 218 LungW/TL (g/mm) A C NT Age (weeks) TAT δv1-1 HT εv1-2 LVW/TL (g/mm) D.3 εv1-2 ventricle specimens from 17-week-old rats were fixed with 1% buffered formalin, embedded in paraffin, and two 5- m sections from 3 to 4 animals were stained with Masson s trichrome. Antitransforming growth factor (TGF)- 1 and anticollagen I goat polyclonal antibodies, anti-gapdh, and -actin mouse monoclonal antibodies (Santa Cruz Biotechnology), as well as anti-tissue inhibitor of matrix metalloproteinase (TIMP) 2 rabbit polyclonal antibody (Chemicon), followed by horseradish peroxidase conjugated goat antirabbit, mouse, or goat IgG antibody were used for immunoblotting. Data were normalized to GAPDH or -actin. Matrix metalloproteinase (MMP)-2 activity was measured by in-gel zymography, as described previously, 2 and quantified using ImageJ 1.35s software ( Collagen Secretion From Primary Cardiac Cultured Fibroblasts Confluent neonatal cultured fibroblasts 8 were serum starved for 48 hours before the addition of TGF- 1 (R&D Systems, 1 ng/ml). V1-2 (1 mol/l) was administered every 4 hours and at 15 minutes before the TGF- 1 addition. Culture media were collected after 24 hours, and collagen content was determined using a Sircol soluble collagen assay kit (Biocolor). Statistics Data are means SEMs. All of the statistical analyses were assessed by 1-way factorial ANOVA with Fisher s test, except for the standard Kaplan-Meier analysis with log-rank test for survival (Figures 1A and 4A) and 2-way repeated ANOVA for systolic blood pressure (Figure S1C and S1D). Results In hypertensive Dahl rats, PKC levels increase by 2-fold during the adaptive hypertrophy (between 11 and 17 weeks) and decline to the levels of normotensive animals thereafter. 1 To determine whether PKC plays a positive or negative role in heart failure and death, we treated hypertensive rats with V1-2 (3 mg/kg per day) or with saline (hypertensive control) from the age of 11 weeks to 17 weeks (Figure S1A). A third group was treated with the PKC-selective inhibitor V1-1 as a negative control, because we found that PKC levels and activity do not change in this model. 1 A fourth group of hypertensive rats was treated with the angiotensin II receptor.2.1 NT Saline TAT δv1-1 εv1-2 TAT δv1-1 HT εv1-2 B HT NT E Fractional Shortening (%) NT TAT δv1-1 HT εv1-2 Figure 1. PKC inhibitor or olmesartan slows down the progression of heart failure. A, Survival rate of rats with hypertension-induced heart failure. Rats were treated for 6 weeks with either saline control (hypertensive control [HT-C], n 12) or equimolar concentrations of TAT carrier peptide control (TAT; n 13), the PKC inhibitor, V1-2 (n 1), V1-1 (n 13), or an angiotensin II receptor blocker, olmesartan (; n 12). The gray area represents treatment duration. B, Shown are examples of morphological changes in the tissue (scale bars, 1 mm; left) of echocardiograms (right). Lung weight to tibial length (LungW/TL; C) and left ventricle weight to tibial length (LVW/TL; D) were measured in 17-week-old rats (n 6 per group), and averaged FS (E) data from each rat group at the age of 17 weeks (n 6). P.5 vs normotensive-control (NT-C); P.5 vs HT-C; P.5 vs hypertensive TAT (HT-TAT). blocker olmesartan, commonly used for the prevention and treatment of heart failure in humans. However, we chose a dose of olmesartan (3 mg/kg per day) that ameliorates heart failure without affecting systolic blood pressure, the etiology of the disease in this model (Figure S1C). Sustained delivery of V1-2 or olmesartan (delivered by daily gavage) between weeks 11 to 17 improved animal survival and improved or normalized FS and other parameters of cardiac function (Figures 1 and 2 and Table S1). The relative increase in cardiac weight was attenuated by olmesartan but not by V1-2 (Figure 1D). (The number of animals in the control-treated group decreased over time, because fewer animals survived without treatment with V1-2.) As expected, because PKC levels do not change with the disease in this animal model, 1 PKC inhibition had no effect on the disease progression (Figure 1), indicating the selective effect of PKC inhibition (we confirmed that the peptide inhibitors selectively inhibited the translocation of their corresponding isozymes and not other PKC isozymes in these hearts; Figure S2). Therefore, while on treatment with the PKC inhibitor or with olmesartan, cardiac dysfunction because of pressure-overload in hypertensive rats diminished. Heart failure is associated with increased parenchymal fibrosis, 9 and sustained treatment with V1-2 (and, to a lesser extent, treatment with olmesartan) reduced left ventricle fibrosis relative to hypertensive-control hearts (Figure 3A). The perivascular fibrosis increase in hypertensive rats was greatly attenuated by treatment with V1-2 but not with olmesartan (Figure 3A, right). Furthermore, collagen I levels in hearts of 17-week old rats were significantly decreased in the V1-2-treated group when compared with the hypertensive control group (Figure 3B). We next measured the levels of one of the major profibrotic cytokines, TGF The ratio of active:latent TGF- 1 was 2-fold higher in the hypertensive group relative to the normotensive age-matched rats. Six weeks of treatment with V1-2, but not with olmesartan, partially inhibited TGF- 1

3 Inagaki et al PKC Inhibition Prevents Heart Failure 3 Downloaded from by guest on July 3, 218 A ESD (mm) B FS (%) N=7 N= N= N=13 N= N=1 N=1 N= Age (week) Age (week) Figure 2. PKC inhibition diminished end-systolic dimension and increased FS. End-systolic dimension (ESD; A) and FS (B) of hypertensive-control (HT) and V1-2 treated groups. P.5. The number of tested animals at each time point is indicated. The gray area indicates the drug treatment period. Because most of the animals died by 19 weeks in the HT group, the differences between the groups at 19 weeks may be underestimated. indicates V1-2group;, HT group. activation (Figure 3C). We also found that the activity of MMP2 levels, one of the major MMPs regulating fibrosis and heart failure, 2 increased in the 17-week old hypertensive rats (234 19% compared with normotensive control rats). This increase was greatly inhibited after PKC inhibition but not by olmesartan (Figure 3D). We next determined whether TIMP2, the major endogenous tissue inhibitor of MMP-2, 11 was affected by PKC inhibition (Figure 3D). The level of TIMP2 increased in the V1-2-treated group relative to the other groups. We next determined whether PKC regulation affects collagen secretion using cultured cardiac fibroblasts (Figure 3E). Collagen secretion increased with TGF- 1 treatment, and V1-2 inhibited it. Because V1-2 treatment did not affect collagen secretion under basal conditions (data not shown), the data suggest that PKC may further contribute to heart failure progression, at least in part, by enhancing TGF- 1 induced collagen release. esartan treatment did not affect the activity or levels of PKC (Figure S2A and S2C), and V1-2 treatment normalized perivascular fibrosis but olmesartan did not (Figure 3). Yet, either treatment increased the life span of the hypertensive rats to a similar extent and decreased the rate of cardiac dysfunction development (Figure 1). These results suggest that the mechanism leading to protection by these 2 agents may be different and that treatment of hypertensive rats with both agents should be additive. Indeed, treatment of the hypertensive rats with both V1-2 and olmesartan up to week 17 increased the life span of the animals by up to an additional 13 weeks as compared with the treatment of olmesartan alone (average survival was 16 5 days after treatment with olmesartan versus days after treatment with olmesartan together with V1-2; Figure 4A). Again, the high blood pressure remained unchanged (Figure S1D), yet V1-2 plus olmesartan-treated animals maintained FS similar to the normotensive control rats (Figure 1E and Table S1), even at the age of 24 weeks, 5 weeks after the treatment with V1-2 and olmesartan terminated (Figure 4B and Table S2). Although the second study did not include a group of animals treated with V1-2 alone, it is likely that the combined treatment of V1-2, together with olmesartan (a commonly used drug for patients with heart failure), is superior to treating with each of these agents alone. Therefore, without affecting hypertension, the cause of the disease, treatment with both the PKC inhibitor and an angiotensin II receptor blocker between weeks 11 and 19 prolonged the lives of the rats by 17 weeks with the 2 inhibitors together and enhanced the therapeutic effect obtained by each treatment alone. The molecular basis for this prolonged longevity remains to be determined. Discussion Using a rat model of hypertension-induced heart failure, we demonstrated that pharmacological inhibition of PKC during the transition from compensatory cardiac hypertrophy to heart failure slowed the progression of heart failure. There was a similar benefit to using the angiotensin II receptor blocker olmesartan. Furthermore, combination treatment with the PKC inhibitor and olmesartan during transition to heart failure appears to provide a sustained effect; animals survived 38 weeks, although the treatment was terminated by week 19. Importantly, these therapeutic effects were not associated with a reduction in blood pressure. We previously found a transient increase in PKC levels at week 11 of the disease with a return to basal levels by 17 weeks. 1 We treated the hypertensive rats with the PKC inhibitor only during the period when PKC was elevated, which is also the transition period from the compensatory to the decompensated stage of the disease. On termination of V1-2 treatment at 17 weeks, there was an increase in end-systolic dimension and a decrease in FS, as measured at 19 weeks (Figure 2), indicating that PKC inhibition delays the development of the disease in this model. Histological analysis showed reduced cardiac fibrosis and collagen I levels with PKC inhibition (Figure 3A and 3B). Yet, PKC null mice showed increased fibrosis and cardiac dysfunction after pressure-overload induced heart failure using transaortic constriction. 6 However, in that model, the change in pressure-overload is very sudden, and an increase in PKC levels was observed, an effect that did not occur in our model (Figure S2B and S2D). Furthermore, we reported previously that PKC activation increases TGF- 1 induced proliferation of cardiac fibroblasts 8 ; perhaps the increase in PKC mediates the observed fibrosis in the PKC null mice or may reflect compensation for the complete absence of

4 4 Hypertension June 28 Downloaded from by guest on July 3, 218 A Hypertensive Normotensive εv1-2 B Collagen I (Ratio to HT-control) Collagen GAPDH C Active/Latent TGFβ1 (Ratio to HT-control) Active TGFβ1 Latent TGFβ1 εv1-2 NT HT εv1-2 NT HT D Secreted Collagen MMP2/TIMP2 (Ratio to no treatment) (Ratio to HT-control) MMP2 TIMP2 E εv1-2 NT HT ε V1-2 TGFβ1 Figure 3. PKC regulates fibrosis in hypertensive (HT) Dahl rats. A, Masson s trichrome staining assessing cardiac fibrosis (blue area). Shown are representative micrographs of parenchymal area (bar 2 m) or of arteries (bar 1 m; n 4 per group). Arrowheads indicate areas of tissue fibrosis. B, Collagen expression in left ventricle tissue in the same samples as in Figure 1 (n 6). P.5 vs HT; P.5 vs normotensive (NT). Bottom, Representative blots. C, The levels of active TGF- 1 presented as a ratio of active dimer form (25-kDa) to latent form (39-kDa; n 6). P.5 vs NT. Bottom, Representative blots. D, Net MMP2 activity presented as a ratio of MMP2 activity (obtained by zymography) divided by the levels of TIMP2 (obtained by Western blot analysis; n 6). A GAPDH level was used as a loading control for TIMP2 measurement. Bottom, Representatives of each measurement. P.5 vs HT. E, Collagen secretion from cultured primary cardiac fibroblasts stimulated with TGF- 1, presented as a ratio to collagen secretion in the absence of TGF- 1 treatment (n 3). P.5 vs negative control with TGF- 1. PKC during development. We also showed that the levels of active TGF- 1, a major fibroblast-regulating factor, were reduced by PKC inhibition in vivo. PKC inhibition also abrogated TGF- 1 induced collagen secretion in vitro. These data are consistent with a profibrotic effect of PKC in failing heart that we observed in vivo. We also found that PKC may modulate cardiac fibrosis by regulating metalloprotease activity (Figure 3D). However, PKC inhibition does not affect fibroblast proliferation. 8 Therefore, the changes in active TGF- 1 levels, collagen secretion, and metalloprotease activity may lead to the decreased collagen accumulation and fibrosis that we have observed in the hypertensive rats treated with the PKC inhibitor. Consistent with other studies, systolic dysfunction develops in these hypertensive rats at 17 weeks and is normalized after treatment with the PKC inhibitor or olmesartan (Table S1 and Figure S2). Because diastolic function was not measured, it remains to be determined whether the decrease in fibrosis by PKC inhibition impacts this function. Kidney dysfunction occurring in these animals 12 may further contribute to heart failure. Because the 1..5 A B εv Age (weeks) Fractional shortening (%) weeks 24 weeks + εv1-2 + εv1-2 Figure 4. Combination treatment with olmesartan and the PKC inhibitor has an additive protective effect in a hypertension (HT)-induced heart failure model. A, Survival rate of rats with HT-induced heart failure treated with the PKC inhibitor, V1-2, together with an angiotensin II receptor blocker, olmesartan (; n 12) or with alone (n 13). The gray area represents the duration of drug treatments. B, FS was determined in 19. P.5 vs alone.

5 Inagaki et al PKC Inhibition Prevents Heart Failure 5 Downloaded from by guest on July 3, 218 PKC inhibitor was delivered systemically, it may benefit other organs, which, in turn, may prevent progression to heart failure. Although acute activation of PKC before ischemia and reperfusion injury in ex vivo rat heart 1,13 or before heterotopic heart transplantation 14 models are cardioprotective, we already found that a 4-week inhibition of PKC is protective against chronic rejection in the heterotopic cardiac transplantation model. 15 Therefore, PKC activation is beneficial in acute response to ischemia but is detrimental in chronic cardiac diseases, demonstrating the importance of the use of selective pharmacological tools that can be administered at defined time points and for a defined period. Perspectives Heart failure is a complex syndrome with multiple etiologies. Whether our findings in these hypertensive rats are translatable to other models of hypertension and whether the same benefits can be seen also in myocardial infarction induced models of heart failure have yet to be determined. Furthermore, most of the analyses were carried out at a single time point (17 weeks), when some of the treatment groups had only 5% survival. The data from the surviving animals may represent events related to a slower disease progression or better compensatory mechanisms relative to animals that had succumbed to the disease. We also find it unlikely that fibrosis inhibition is the sole mechanism leading to the benefits afforded by V1-2. The molecular pathways in both cardiac myocytes and nonmyocytes remain to be elucidated. Finally, we did not determine whether sustained treatment will remain beneficial or whether PKC inhibition and/or an angiotensin receptor blocker provide only a short-term benefit. Nevertheless, because the period of treatment covered the time from compensated to decompensated hypertrophy in this model, our study suggests that sustained inhibition of PKC early during decompensatory hypertrophy may delay or inhibit the development of heart failure. Together, our data suggest that an PKC inhibitor, such as V1-2, may augment current therapeutic strategies for the treatment of heart failure in humans. Acknowledgment We are grateful to Dr Dan Bernstein for helpful discussions and advice. Sources of Funding This study was supported by National Institutes of Health grant HL76675 to D.M.-R. K.I. was supported in part by a fellowship grant from Sankyo Co. N.C.B. was a research fellow supported by the Stanley J. Sarnoff Cardiovascular Research Foundation, Inc. L.S. was supported in part by a Stanford Graduate Fellowship. Disclosures D.M.-R. is the founder of KAI Pharmaceuticals, Inc, a company that plans to bring protein kinase C regulators to the clinic. However, none of the work described in this study is based on or supported by the company. The other authors have no disclosures. References 1. Inagaki K, Iwanaga Y, Sarai N, Onozawa Y, Takenaka H, Mochly-Rosen D, Kihara Y. Tissue angiotensin II during progression or ventricular hypertrophy to heart failure in hypertensive rats; differential effects on PKC epsilon and PKC beta. J Mol Cell Cardiol. 22;34: Iwanaga Y, Aoyama T, Kihara Y, Onozawa Y, Yoneda T, Sasayama S. Excessive activation of matrix metalloproteinases coincides with left ventricular remodeling during transition from hypertrophy to heart failure in hypertensive rats. J Am Coll Cardiol. 22;39: Sabri A, Steinberg SF. Protein kinase C isoform-selective signals that lead to cardiac hypertrophy and the progression of heart failure. Mol Cell Biochem. 23;251: Dorn GW II, Souroujon MC, Liron T, Chen CH, Gray MO, Zhou HZ, Csukai M, Wu G, Lorenz JN, Mochly-Rosen D. Sustained in vivo cardiac protection by a rationally designed peptide that causes epsilon protein kinase C translocation. Proc Natl Acad Sci U S A. 1999;96: Gu X, Bishop SP. Increased protein kinase C and isozyme redistribution in pressure-overload cardiac hypertrophy in the rat. Circ Res. 1994;75: Klein G, Schaefer A, Hilfiker-Kleiner D, Oppermann D, Shukla P, Quint A, Podewski E, Hilfiker A, Schroder F, Leitges M, Drexler H. Increased collagen deposition and diastolic dysfunction but preserved myocardial hypertrophy after pressure overload in mice lacking PKCepsilon. Circ Res. 25;96: Inagaki K, Begley R, Ikeno F, Mochly-Rosen D. Cardioprotection by epsilon-protein kinase C activation from ischemia: continuous delivery and antiarrhythmic effect of an epsilon-protein kinase C-activating peptide. Circulation. 25;111: Braun MU, Mochly-Rosen D. Opposing effects of delta- and zeta-protein kinase C isozymes on cardiac fibroblast proliferation: use of isozymeselective inhibitors. J Mol Cell Cardiol. 23;35: Brown RD, Ambler SK, Mitchell MD, Long CS. The cardiac fibroblast: therapeutic target in myocardial remodeling and failure. Ann Rev Pharmacol Toxicol. 25;45: Booz GW, Baker KM. Molecular signalling mechanisms controlling growth and function of cardiac fibroblasts. Cardiovasc Res. 1995;3: Brew K, Dinakarpandian D, Nagase H. Tissue inhibitors of metalloproteinases: evolution, structure and function. Biochim Biophys Acta. 2; 1477: Tobian L. Salt and hypertension. Lessons from animal models that relate to human hypertension. Hypertension. 1991;17:I52 I Chen L, Hahn H, Wu G, Chen CH, Liron T, Schechtman D, Cavallaro G, Banci L, Guo Y, Bolli R, Dorn GW II, Mochly-Rosen D. Opposing cardioprotective actions and parallel hypertrophic effects of delta PKC and epsilon PKC. Proc Natl Acad Sci U S A. 21;98: Tanaka M, Terry RD, Mokhtari GK, Inagaki K, Koyanagi T, Kofidis T, Mochly-Rosen D, Robbins RC. Suppression of graft coronary artery disease by a brief treatment with a selective epsilonpkc activator and a deltapkc inhibitor in murine cardiac allografts. Circulation. 24;11: II194 I Koyanagi T, Noguchi K, Ootani A, Inagaki K, Robbins RC, Mochly-Rosen D. Pharmacological inhibition of epsilon PKC suppresses chronic inflammation in murine cardiac transplantation model. J Mol Cell Cardiol. 27;43:

6 Pharmacological Inhibition of?-protein Kinase C Attenuates Cardiac Fibrosis and Dysfunction in Hypertension-Induced Heart Failure Koichi Inagaki, Tomoyoshi Koyanagi, Natalia C. Berry, Lihan Sun and Daria Mochly-Rosen Downloaded from by guest on July 3, 218 Hypertension. published online April 14, 28; Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX Copyright 28 American Heart Association, Inc. All rights reserved. Print ISSN: X. Online ISSN: The online version of this article, along with updated information and services, is located on the World Wide Web at: Data Supplement (unedited) at: Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Hypertension can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: Subscriptions: Information about subscribing to Hypertension is online at:

7 Manuscript Number; HYPERTENSION/27/19637 Pharmacological inhibition of εpkc attenuates cardiac fibrosis and dysfunction in hypertension-induced heart failure Short title: εpkc inhibition prevents heart failure Koichi Inagaki, MD, PhD; Tomoyoshi Koyanagi, PhD; Natalia C. Berry; Lihan Sun; Daria Mochly-Rosen, PhD Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, CA Correspondence to: Daria Mochly-Rosen, Ph.D. Department of Chemical and Systems Biology Stanford University School of Medicine CCSR, Rm 3145A, 269 Campus Drive Stanford, CA Tel: Fax: KI and TK contributed equally to this study. Current address; Otsu Red-Cross Hospital, Shiga, Japan,

8 REFERENCES 1. Inagaki K, Iwanaga Y, Sarai N, Onozawa Y, Takenaka H, Mochly-Rosen D, Kihara Y. Tissue angiotensin II during progression or ventricular hypertrophy to heart failure in hypertensive rats; differential effects on PKC epsilon and PKC beta. J Mol Cell Cardiol. Oct 22;34(1): Dorn GW, 2nd, Souroujon MC, Liron T, Chen CH, Gray MO, Zhou HZ, Csukai M, Wu G, Lorenz JN, Mochly-Rosen D. Sustained in vivo cardiac protection by a rationally designed peptide that causes epsilon protein kinase C translocation. Proceedings of the National Academy of Sciences of the United States of America. 1999;96(22): Inagaki K, Begley R, Ikeno F, Mochly-Rosen D. Cardioprotection by epsilonprotein kinase C activation from ischemia: continuous delivery and antiarrhythmic effect of an epsilon-protein kinase C-activating peptide. Circulation. Jan 4 25;111(1):44-5.

9 Supplemental Figure 1: (A): Scheme of the treatment protocol of the experiments described in Figures 1-3. (B): Scheme of the treatment protocol of the experiments described in Figure 4. (C): Systolic blood pressure was measured at the age of 11, 13, 15 and 17 weeks (n=6-17 per group) for animals treated as in the protocol in A (left) or in B (right). (D): Systolic blood pressure was measured at the age of 11, 15, 19 and 24 weeks for the animals treated as in the protocol in B. (E): Initial cardiac functions were the same for all treatment groups at the start of the treatment (e.g., data for the protocol in A). Averaged fractional shortening from each group at the age of 11 weeks before any drug treatment has begun. εv1-2 (an εpkc inhibitor, derived from the V1 region of the enzyme, amino acids [EAVSLKPT]) and the δpkc inhibitor, δv1-1 (derived from the V1 region of δpkc, amino acid 8-17 [SFNSYELGSL]) were synthesized and conjugated to TAT (carrier peptide, amino acids [YGRKKRRQRRR]) via a disulfide bond at American Peptides (Sunnyvale, CA).] 4,7

10 Supplemental Figure 2: The selective effect of sustained treatment with εv1-2 on εpkc. Western blot analyses of the total LV lysates (A and B, respectively) or soluble and particulate fractions (C and D, respectively; n=6 per group) of ε and δpkc in each fraction. Quantitative data are presented as a ratio to low-salt control (NT). β-actin or GAPDH were used as loading controls for the particulate (P) and the soluble (S) fractions, respectively. n=6 for each. P<.5 vs. NT, P<.5 vs. HT. The levels and translocation of ε and δpkc in LV tissues from 17-week-old rats were determined by western blot analysis, as previously reported. 1 All data were normalized by internal controls of GAPDH or β-actin.

11 Supplemental Table 1. Body weight and in vivo echocardiographic data. Group n BW (g) PWT (mm) EDD (mm) ESD (mm) FS (%) NT-Control ±5 1.6±. 7.±.1 2.9±.2 6± ±18 1.5±.1 7.4±.4 4.4±.6 41±6 HT εv ±7 1.6±.1 7.±.1 2.9±.2 58± ±8 1.5±. 7.5±.2 3.5±.2 53±2 Body weight (BW) and echocardiographic data (PWT; diastolic posterior LV wall thickness, EDD; end-diastolic dimension, ESD; end-systolic dimension, FS; fractional shortening) were measured at 17 weeks of age, when the pharmacological treatments were terminated. Values are mean ± SEM. P <.5 vs. NT-C; P <.5 vs. HT-Control (±. denotes SEM smaller than.5)

12 Supplemental Table 2: Body weight and in vivo echocardiographic data of combination treatment and of olmesartan alone. Group n BW (g) PWT (mm) EDD (mm) ESD (mm) FS (%) 6 423±15 1.5±. 7.9±.2 4.9±.5 38±5 +εv ±13 1.5±. 7.2±.1 3.4±.3 54±4 The same parameters as in Table 1 were measured at 24 weeks of age (5 weeks after the pharmacological treatments were terminated). Values are mean ± SEM. P <.5 vs.. (±. denotes SEM smaller than.5)

13 e A 6 11 Low salt 1 /+εv Age High salt diet (weeks) Saline/TAT/δV1-1/εV1-2/ B Age Low salt High salt diet (weeks) C Systolic blood pressure Saline TAT V1-1 εv Age (weeks) D Systolic blood pressure (mmhg) Age (weeks) +εv E NT TAT δv1-1 εv1-2 HT Supplemental Figure 1: Inagaki et al.

14 Supplemental Figure 2 Inagaki et al.