cancer: a disease marked by tumor-like growth —Merriam-Webster’s Ninth Collegiate Dictionary In the world according to Webster, heart failure is a form of cardiac cancer. Although primary cardiac malignancies are among the most rare of human diseases, this singular viewpoint is substantiated by the massive, abnormal, “tumor-like” growth in cardiac muscle that accompanies heart failure. The biological principles of cell growth, death, and survival are as important in the onset of heart failure as in tumor progression, and the molecular signals for cell proliferation and cardiac myocyte hypertrophy are highly conserved. Both diseases are inexorable and progressive, characterized by clinical stages that predict survival and outcome, ultimately resulting in a terminal phase. There are “multi-hit” pathways for both cancer and heart failure progression, largely based upon the interplay between genetic susceptibility and environmental stimuli. Like cancer, heart failure represents one of the most important unmet clinical needs in medicine today. Heart failure remains poorly understood and is largely treated symptomatically by a complex regimen of drugs whose actions we are neither entirely sure of nor comfortable with. The lack of new biologically targeted therapy reflects the combined result of the prohibitive cost of large-scale survival trials of adjunctive therapy designed to incrementally slow heart failure progression, and the lack of clear clinical and/or molecular surrogates that have predictive value. In short, the pipeline of heart failure drugs is running dry. Perhaps the time has come to attempt to dissect the mixed signals for heart failure from the viewpoint of recent advances in cancer biology. On a molecular level, the failing heart represents the end result of multiple cues for the growth, death, and survival of cardiac myocytes, many of which are shared with signaling pathways in cancer biology (1, 2). In the failing heart, the underlying disease is also driven by multiple positive and negative signaling pathways, but these are connected to specific phenotypic endpoints that are more physiologically complex, e.g., electrical conduction, contractility, relaxation, mechanical activation, and chamber morphogenesis (Figure (Figure1).1). The development of new, biologically targeted therapies for cancer has been fostered by placing therapy into the framework of fundamental pathways that control the cell cycle and subsequent tumor cell proliferation. In a similar manner, understanding the molecular logic of heart failure will ultimately require forming mechanistic connections between defined clinical disease surrogates with specific positive and negative molecular checkpoints that arise at specific stages during the natural temporal progression of this chronic disease. In the current post-genome world, a new wave of work in heart failure has begun to attack the integrative biology of heart failure at multiple levels: genomic, genetic, and physiological in creatures great and small (3). This brief review will highlight recent progress in the field and point out new directions for research into this disease process. Figure 1 Mechanical stress–induced transmembrane signaling and integrated phenotypes of failing heart. The activation profiles of various signaling cascades and time-dependent changes in phenotypic features of heart failure are illustrated based on our ... Note. Interested readers are referred to the supplemental reading list (www.jci.org/cgi/content/full/109/7/849/DC1) for detailed references to the data presented in the tables and figures.
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