Acyl ghrelin improves cardiac function in heart failure and increases fractional shortening in cardiomyocytes without calcium mobilization.

Background and Aims: Ghrelin is an endogenous appetite-stimulating peptide hormone with potential cardiovascular benefits. Effects of acylated (activated) ghrelin were assessed in patients with heart failure and reduced ejection fraction (HFrEF) and in ex vivo mouse cardiomyocytes.
Methods and Results: In a randomized placebo-controlled double-blind trial, 31 patients with chronic HFrEF were randomized to synthetic human acyl ghrelin (0.1 µg/kg/min) or placebo intravenously over 120 min. The primary outcome was change in cardiac output (CO). Isolated mouse cardiomyocytes were treated with acyl ghrelin and fractional shortening and calcium transients were assessed. Acyl ghrelin but not placebo increased cardiac output (acyl ghrelin: 4.08 ± 1.15 to 5.23 ± 1.98 L/min; placebo: 4.26 ± 1.23 to 4.11 ± 1.99 L/min, P < 0.001). Acyl ghrelin caused a significant increase in stroke volume and nominal increases in left ventricular ejection fraction and segmental longitudinal strain and tricuspid annular plane systolic excursion. There were no effects on blood pressure, arrhythmias, or ischaemia. Heart rate decreased nominally (acyl ghrelin: 71 ± 11 to 67 ± 11 b.p.m.; placebo 69 ± 8 to 68 ± 10 b.p.m.). In cardiomyocytes, acyl ghrelin increased fractional shortening, did not affect cellular Ca2+ transients, and reduced troponin I phosphorylation. The increase in fractional shortening and reduction in troponin I phosphorylation was blocked by the acyl ghrelin antagonist D-Lys 3.
Conclusion: In patients with HFrEF, acyl ghrelin increased cardiac output without causing hypotension, tachycardia, arrhythmia, or ischaemia. In isolated cardiomyocytes, acyl ghrelin increased contractility independently of preload and afterload and without Ca2+ mobilization, which may explain the lack of clinical side effects. Ghrelin treatment should be explored in additional randomized trials.
Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT05277415.
Competing Interests: Conflict of interest Lars H Lund: Grants: AstraZeneca, Vifor, Boston Scientific, Boehringer Ingelheim, Novartis; consulting: Merck, Vifor, AstraZeneca, Bayer, Pharmacosmos, MedScape, Sanofi, Lexicon, Myokardia, Boehringer Ingelheim, Servier; speaker’s honoraria: Abbott, MedScape, Radcliffe, AstraZeneca, Novartis; stock ownership and founder: AnaCardio (a start-up company dedicated to developing acyl ghrelin analogues for the treatment of heart failure). Camilla Hage: consulting fees from Novartis, Roche Diagnostics, and AnaCardio, research grants from Bayer, and speaker’s honoraria from MSD and Novartis. Marcus Ståhlberg: consulting fees: AnaCardio, Impulse Dynamics, Swedish Agency for Health Technology Assessment and Assessment of Social Services; speaker’s honoraria: Medtronic, Orion Pharma, ALK-Nordic, Werfen. Ulrika Ljung-Faxen: consulting fees: AnaCardio, lecture fees: Orion Pharma. Per Hellström: consulting fees: Phamranovia, RenaPharma, Milltons. Tonje Thorvaldsen: lecture fees Orion Pharma, Boehringer Ingelheim, Abbott. All other authors report no conflicts of interest.
(© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)