Mechano-energetic uncoupling in hypertrophic cardiomyopathy: Pathophysiological mechanisms and therapeutic opportunities

Abstract

Hypertrophic cardiomyopathy (HCM) is a frequent inherited form of heart failure. The underlying cause of HCM is generally attributed to mutations in genes that encode for sarcomeric proteins, but the pathogenesis of the disease is also influenced by non-genetic factors, which can contribute to diastolic dysfunction and hypertrophic remodeling. Central to the pathogenesis of HCM is hypercontractility, a state that is an antecedent to several key derangements, including increased mitochondrial workload and oxidative stress. As a result, energy depletion and mechano-energetic uncoupling drive cardiac growth through signaling pathways such as ERK and/or potentially AMPK downregulation. Metabolic remodeling also occurs in HCM, characterized by decreased fatty acid oxidation and increased glucose uptake. In some instances, ketones may also feed the heart with energy and act as signaling molecules to reduce oxidative stress and hypertrophic signaling. In addition, arrhythmias are frequently triggered in HCM, resulting from the high Ca²⁺-buffering of the myofilaments and changes in the ATP/ADP ratio. Understanding the mechanisms driving the progression of HCM is critical to the development of effective therapeutic strategies. This paper presents evidence from both experimental and clinical studies that support the role of hypercontractility and cellular energy alterations in the progression of HCM towards heart failure and sudden cardiac death.