We have previously demonstrated that the mineralocorticoid receptor (MR) plays an important role in inflammation in atherosclerosis. Studies from our laboratory suggest a role for monocyte MR activation in monocyte/macrophage inflammation. Further, we have demonstrated a key role for candidate microRNAs (miRNAs) in the regulation of MR (NR3C2) gene expression in monocytes and in the prediction of atherosclerosis. These findings suggest that miRNA expression predicts response to MR blockade in patients. We propose a randomized double blind clinical trial to assess the effect of MR antagonism on atherosclerosis in type II diabetes (DM).
In Aim 1, we will test the effect of the MR antagonist Eplerenone (Epl) or placebo on progression of atherosclerosis using high resolution MRI. Key secondary outcomes will include central aortic blood pressure, pulse wave velocity, and measures of insulin resistance while tertiary measures include novel makers of heart failure predisposition.
In Aim 2, we hypothesize that expression of monocyte miRNAs and macrophage phenotype may serve as markers of risk, disease progression, and response to MR antagonist. We propose investigating this in three, linked sub-aims.
In Aim 2 a, we will investigate the functional significance of single or multiple miRNAs involved in the regulation of MR expression using a promoter- reporter-3'UTR construct of the NR3C2 gene in cultured human macrophages.
In Aim 2 b, monocyte polarization and inflammatory genes will be compared at 6-weeks in Epl/placebo patients.
In Aim 2 c, at baseline we will measure the expression of miRNAs in monocytes predicted to regulate NR3C2. In addition we will measure NR3C2 transcript and/or protein expression in the same cells. Differential regulation of miRNAs after 6 weeks of treatment will be measured and used to understand disease progression and therapeutic effects of MR blockade. Using state of the art methods to quantify atherosclerosis with the latest advances in vascular biology, this proposal will offer an unprecedented opportunity to elucidate whether MR blockade is effective in atherosclerosis and further provide much needed insights on pathophysiologically relevant mechanisms and predictors of response. The insights from this study may lead to appropriately designed outcome trials.

Public Health Relevance

Atherosclerosis (hardening of the arteries) is the leading cause of morbidity and mortality in Type II diabetes. A cell type called the monocyte/macrophage is critical to development and complications of atherosclerosis. This project will evaluate the effectiveness of a medication called Eplerenone in preventing atherosclerosis in Type II diabetes through its effects on cells such as the monocyte. Eplerenone is scheduled to become generic in 2015 and has been demonstrated to be effective for the treatment of patients after a heart attack and stroke. We will evaluate the impact of Eplerenone in reducing atherosclerosis plaque and additionally evaluate its potential in changing inflammation. We envision that our strategy of simultaneously probing effect of a drug combined with analysis of mechanisms of action and predictive response will likely provide key information with which to design hard event (heart attack, stroke etc.) based trials.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
Research Project (R01)
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Clinical and Integrative Cardiovascular Sciences Study Section (CICS)
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Fleg, Jerome L
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Case Western Reserve University
Internal Medicine/Medicine
Schools of Medicine
United States
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Spanakis, Elias K; Levitt, David L; Siddiqui, Tariq et al. (2018) The Effect of Continuous Glucose Monitoring in Preventing Inpatient Hypoglycemia in General Wards: The Glucose Telemetry System. J Diabetes Sci Technol 12:20-25
Belden, Zachary; Deiuliis, Jeffrey A; Dobre, Mirela et al. (2017) The Role of the Mineralocorticoid Receptor in Inflammation: Focus on Kidney and Vasculature. Am J Nephrol 46:298-314
Rajagopalan, Sanjay; Alaiti, M Amer; Broadwater, Kylene et al. (2017) Design of the Magnetic Resonance Imaging Evaluation of Mineralocorticoid Receptor Antagonism in Diabetic Atherosclerosis (MAGMA) Trial. Clin Cardiol 40:633-640
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