Cleavage of cyclic AMP-responsive element-binding protein H aggravates myocardial hypoxia reperfusion injury in a hepatocyte-myocardial cell co-culture system.

OBJECTIVE: This study aimed to determine whether proinflammatory cytokines have an effect on myocardial cells (MCs) and hepatocytes during myocardial ischemia to induce cyclic AMP-responsive element-binding protein H (CREBH) cleavage, activate the acute phase response in the liver, and cause a superimposed injury in MCs.
METHODS: In this study, a hepatocyte-MC transwell co-culture system was used to investigate the relationship between myocardial hypoxia/reperfusion injury and CREBH cleavage. MCs and hepatocytes of neonatal rats were obtained from the ventricles and livers of Sprague-Dawley rats, respectively. MCs were inoculated into the lower chamber of transwell chambers for 12 hours under hypoxia. Levels of the endoplasmic reticulum stress protein glucose-regulated protein 78 in MCs, CREBH in hepatocytes, inflammatory factor (tumor necrosis factor-α and interleukin-6) levels, and cell viability were evaluated. The effect of CREBH knockdown was also studied using a CREBH-specific short hairpin RNA (Ad-CREBHi).
RESULTS: We found that proinflammatory cytokines affect MCs and hepatocytes during myocardial ischemia to induce CREBH cleavage, activate the acute phase response in the liver, and cause superimposed injury in MCs.
CONCLUSIONS: Expression of CREBH aggravates myocardial injury during myocardial ischemia.

Introduction

Myocardial ischemia/reperfusion (I/R) injury is a pathological phenomenon of myocardial injury caused by recovery of blood flow after an episode of myocardial infarction.[1] Myocardial I/R injury increases myocardial structural injury, leading to myocardial cell (MC) death, and has a negative effect on the patient’s prognosis. Myocardial I/R injury mainly involves calcium overload, abundance of oxygen radicals, and occurrence of vascular endothelial dysfunction, constituting the so-called classic myocardial I/R injury.[2] The systemic inflammatory response is an important mechanism of myocardial I/R injury and levels of inflammatory factors, are significantly increased in patients with myocardial infarction.[3] Moreover, these inflammatory factors not only indicate an inflammatory response, but also directly play a role in myocardial injury.[4] In contrast, some cytotoxic anti-inflammatory drugs, such as cyclophosphamide, can reduce systemic and local myocardial inflammatory responses.[5] additionally, the endoplasmic reticulum stress (ERS)-mediated acute phase response (APR) can induce inflammatory responses and aggravate myocardial injury.[6] However, to the best of our knowledge, there is no evidence regarding whether myocardial local inflammation is involved in development of the APR.

ERS is induced by oxidative stress, calcium overload, nutrient deprivation, viral infection, and hypoxia.[7,8] Classical ERS is caused by unfolded or misfolded protein accumulation, which is induced by the above-mentioned factors.[8] The unfolded protein response (UPR) signaling cascade is activated by the three main UPR sensors of protein kinase-like endoplasmic reticulum kinase, inositol-requiring enzyme 1α, and activating transcription factor (ATF) 6.[9,10] However, recent evidence has indicated that cyclic AMP-responsive element-binding protein H (CREBH) contains a transcription factor and belongs to the CREB/ATF family, which mediates the intrahepatic APR in vivo.[6]

C-reactive protein (CRP) is a part of the nonspecific APR protein that regulates expression of APR genes.[11] CREBH cleavage is induced by lipopolysaccharide and proinflammatory cytokines during APR activation and CRP expression in the liver. High serum CRP levels are important for assessing the risk of myocardial infarction and may play a role in promoting atherosclerosis during APR. Furthermore, in severe acute coronary syndrome (ACS), accumulation of inflammatory cells is observed because of formation and progression of intracoronary plaques until their rupture.[12,13] Therefore, the APR in patients with ACS is significantly related to ischemic myocardial injury.

CREBH is highly expressed in the liver. I/R injury due to CREBH cleavage in the liver might induce ERS-mediated inflammation in MCs, leading to activation of a systemic stress reaction and release of proinflammatory cytokines. Additionally, CREBH cleavage might activate expression of APR genes, induce a systemic inflammatory response, and eventually aggravate myocardial injury. Recent studies have shown that ERS-mediated APR can induce inflammatory responses, and their coupling may lead to development of myocardial injury. The main aim of our study was to determine whether proinflammatory cytokines have an effect on MCs and hepatocytes during myocardial ischemia to induce CREBH cleavage, activate the APR in the liver, and cause superimposed injury in MCs. A hepatocyte–MC transwell co-culture system for determining whether CREBH has a proinflammatory effect in co-culture was used in our investigation to test the assumptions made above.

Materials and methods

Isolation and primary culture of MCs and hepatocytes from neonatal rats

One-day-old neonatal Sprague–Dawley rats were provided by the Zhejiang Laboratory Animal Center. Routine methods were used to culture the MCs at a concentration of 1 × 106 cells/mL in Dulbecco’s modified Eagle’s medium (DMEM) supplemented with 10% fetal bovine serum and 100 µM 5-bromo-2-deoxyuridine. After 36 hours of incubation at 37°C with 5% CO2, the medium was changed to DMEM without 5-bromo-2-deoxyuridine, and incubation of the cells continued under the same conditions. The culture medium was changed every 3 days.[14]

Liver cells from neonatal Sprague–Dawley rats were isolated via cold trypsin digestion of a tissue sample combined with multi-step, low-speed centrifugation. Thereafter, cells were cultured on a plate in HepatoZYME-SFM (Hangzhou, Zhejiang, China) containing 10% fetal bovine serum, 9.6 mg/mL prednisolone, 0.16 U/mL insulin, 0.014 mg/mL glucagon, 100 U/mL penicillin, and 100 U/mL streptomycin at 37°C in an incubator containing 5% CO2.[15] Cell yield and viability were measured with trypan blue exclusion. The medium was changed every 24 hours. Every procedure was approved by the Animal Care and Use Committee of The First Affiliated Hospital of Wenzhou Medical University.

Hypoxia/reperfusion of MCs

To simulate the hypoxia/reperfusion (H/R) process, 5-day cultured MCs were transferred into an anaerobic chamber and cultured at 37°C for 2 hours. Hypoxia was then stopped, and the cells were cultured in DMEM containing 10% fetal bovine serum at 37°C with 5% CO2 for 2 hours.[16] ERS-positive control cultures were set up using tunicamycin (Tm, 5 μg/mL).

MCs were treated with H/R (2 hours each) and the importance of ERS in myocardial injury was examined by investigating the effect of Tm. ERS protein levels (antibodies: glucose-regulated protein [GRP] 78, 11587-1-AP; Proteintech, Chicago, IL, USA and CREBH, ab111938; Abcam, Cambridge, MA, USA), inflammatory factor levels (tumor necrosis factor-α [TNF-α], ab46070; Abcam and interleukin-6 [IL-6], ab222503; Abcam), and cell viability were assessed.

Recombinant adenovirus and transfection

For endogenous knockdown of CREBH expression in MC cells, we applied a recombinant adenovirus system. Adenovirus for the unspecific (Ad-USi) control and CREBH RNAi (Ad-CREBHi) were obtained from Shanghai Jima Pharmaceutical Technology Co., Ltd (Shanghai, China). Recombinant adenoviruses were amplified in MCs and were purified with the Adeno-X Virus Maxi Purification kit (Clontech, Palo Alto, CA, USA). The virus titer was determined using the Adeno-X Rapid Titer kit (BD Biosciences, San Jose, CA, USA). Forty-eight hours after infection with AD-USi or Ad-CREBHi, total RNA was isolated using Tri Reagent (Sigma, St Louis, MO, USA) according to the manufacturer’s instructions.

Transwell co-culture

In the co-culture system, the cells were in medium without any contact. A 24-well permeable support (Corning, New York, NY, USA; well size: 0.4 µm; Figure 1) was used. The following six cell groups were established in the experiment: Three of these groups included MCs without hepatocytes as follows: (1) MCs were cultured in the lower chamber and medium alone was placed in the upper chamber (MCs group); (2) MCs alone were cultured in the lower compartment and were subjected to H/R (MCs + H/R group); and (3) MCs alone were cultured in the lower compartment with Tm (5 μg/mL) (MCs + Tm group). The other three groups included MCs plus co-culture with hepatocytes as follows: (1) MCs were cultured in the lower compartment and hepatocytes were cultured in the upper compartment (L/M group); (2) MCs were seeded in the lower compartment and subjected to hypoxia in an anaerobic chamber for 12 hours, and normal liver cells were added to the upper compartment followed by reoxygenation for 12 hours (L/M + H/R group); and (3) MCs were cultured in the lower chamber with Tm (5 μg/mL) for 12 hours (L/M + Tm group). Thereafter, the medium was changed to DMEM without Tm in the L/M + Tm group, and normal hepatocytes were added to the upper chamber and re-oxygenated for 12 hours to simulate H/R.

Figure 1.

Illustration of the co-culture system.

Assessment of MC proliferation

The beating frequencies of cultured MCs were determined after treatment. The Cell Counting Kit-8 (CCK-8; C0037; Beyotime) was used to evaluate proliferation of MCs as per the manufacturer’s instructions. The CCK-8 test, which is a colorimetric assay, is indirectly used as a cell viability indicator via measurement of cell metabolic activity.[17] After treatment, the upper chamber was removed, and 50 µL of CCK-8 solution was added to each well of the lower chamber. After incubation at 37°C for 1 hour, the absorbance (optical density [OD]) for each well was measured at 450 nm on a microplate reader. Each sample was analyzed in triplicate. The viability of cells was calculated using the following formula:

Western blot analyses

After washing the cells twice with phosphate-buffered saline, the cells were lysed and separated in cell lysis buffer (20 mM Tris, pH 7.5, 1% Triton X-100, 150 mM NaCl, 1 mM EDTA, 2.5 mM sodium pyrophosphate, 0.5 μg/mL leupeptin, 1% Na3VO4, 1 mM phenylmethanesulfonyl fluoride). Protein was then quantified using the bicinchoninic acid protein assay. The lysates were incubated on ice for 30 minutes. Thereafter, they were centrifuged at 10,000 × g at 4°C for 5 minutes. An equivalent amount of protein (20 μg) was added to a 10% gel using sodium dodecyl sulfate-polyacrylamide gel electrophoresis and subsequently transferred to a polyvinylidene fluoride membrane. After blocking with Tris-buffered saline containing 0.1% Tween-20 and 5% milk (TBST), each membrane was cultured with their primary antibodies. Protein in MCs was incubated with primary antibodies against glyceraldehyde-3-phosphate dehydrogenase (GAPDH) (dilution of 1:1000, 10494-1-AP; Proteintech) and GRP78 (dilution of 1:1000, 11587-1-AP; Proteintech). Protein in hepatocytes was incubated with primary antibodies against GAPDH (dilution of 1:1000) and CREB (dilution of 1:1000; ab111938; Abcam). The membranes were incubated overnight at 4°C. After washing with TBST three times, the membranes were incubated for 1 hour with secondary antibodies (dilution of 1:5000) at room temperature. Western Bright ECL (Nanjing Biotechnology Co., Ltd., Nanjing, China) was used to detect the corresponding immunoreactive protein bands on the membranes using the Gluing Imaging System (Shanghai Shanfu Scientific Instrument Co., Ltd., Shanghai, China). The bands were analyzed using Image Lab 4.1 software (Bio-Rad, Richmond, CA, USA).

Detection of TNF-α and IL-6 levels using an enzyme-linked immunosorbent assay

TNF-α and IL-6 levels were detected by enzyme-linked immunosorbent assays (Shanghai Enzyme-linked Biotechnology Co., Ltd., Shanghai, China). Blanks and standard dilutions were added to the blank wells of the assay plate, and different concentrations of standards (100 µL/well) were added to the other corresponding wells. The reaction wells were sealed with sealing tape and incubated at 36°C for 90 minutes. The biotinylated antibody working solution was prepared 20 minutes in advance. The plates were washed five times. Biotinylated antibody dilution solution was then added to the blank wells, and the remaining wells biotinylated antibody working solution added (100 µL/well). The reaction wells were sealed with fresh sealing tape and incubated at 36°C for 60 minutes. The plates were washed again for five times. Enzyme conjugate dilution solution was added to blank wells, and the remaining wells had enzyme conjugate working solution added (100 µL/well). The reaction wells were sealed with fresh sealing tape and incubated at 36°C for 30 minutes in the dark. The plates were washed for five times. Chromogenic substrate (TMB) was added (100 µL/well) and the plates were incubated in the dark at 36°C. Stop solution was finally added and the OD450 value was measured (within 3 minutes) immediately after mixing.

Isolation of RNA and reverse transcription-polymerase chain reaction

According to the manufacturer’s instructions, total RNA was isolated from cultured MCs and hepatocytes using TRIzol reagent. To quantify gene transcription, the Revert Aid First Strand cDNA Synthesis kit (Thermo Fisher Scientific, Waltham, MA, USA) was used to generate cDNA. Forward and reverse primers of specific genes and the SYBR Green qPCR kit (Roche, Basel, Switzerland) were used to detect cDNA on the 7500 Real-Time PCR System (Applied Biosystems, Foster City, CA, USA). The following cycling conditions were adopted: 94°C for 1 minute, 35 cycles of denaturing for 30 seconds at 94°C, annealing for 2 minutes at 60°C, and extension for 1 minute at 72°C. Expression levels mRNA in different samples were normalized against GAPDH and analyzed using 7500 system SDS software (Applied Biosystems). Relative mRNA levels were evaluated using the 2–ΔΔCt method.[18] The primer sequences for GRP78 were as follows: forward primer, ACTCCAGGTTAACTC and reverse primer, GCATCCTGCATCCTT.

Statistical analysis

Data were analyzed using IBM SPSS version 22.0 (IBM Corp., Armonk, NY, USA). Experimental data are expressed as mean ± standard deviation. All of the experiments were repeated at least three times. Variance analysis was used for statistical analysis and Scheffe’s test was used for multiple comparisons. P < 0.05 indicates statistical significance.

Results

Analyses of GRP78 and CREBH protein expression using western blotting

ERS-positive control cultures were established using Tm. GRP78 levels were significantly higher in the MCs + H/R group and the MCs + Tm group (positive control group) than in the MCs group (untreated control group) (both P < 0.05, Figure 2a, b). Therefore, H/R appeared to have induced ERS in MCs, and co-culture with hepatocytes enhanced expression levels of GRP78 and CREBH (Figure 2c, d). This result indicated that CREBH cleavage in the liver might induce ERS-mediated inflammation in MCs.

Figure 2.

GRP78 and CREBH protein expression using western blotting. a: Western blotting results of GRP78 protein expression levels. b: Statistical analyses of results shown panel “a”. c: Results of western blotting of CREBH protein expression levels. d: Statistical analyses of results shown in panel “c”. e: Results of western blotting analyses of knockdown of CREBH protein levels in the hepatocytes using adenoviruses encoding CREBH-specific shRNA (Ad-CREBHi). f: Statistical analyses of results shown in panel “e”. Note: *P < 0.05 vs the MCs group, #P < 0.05 vs the L/M + Tm group, $P < 0.05, $$P < 0.01 vs CREBH-N.

Tm: tunicamycin, H/R: hypoxia/reperfusion, MCS: myocardial cells, L/M: lower compartment and hepatocytes, Ad-USi: adenovirus for the unspecific, Ad-CREBHi: adenovirus for cyclic AMP-responsive element-binding protein H (CREBH) RNA.i

The CREBH gene was silenced using adenoviruses encoding CREBH-specific shRNA (Ad-CREBHi) in H/R-induced ERS-mediated inflammation to study the effect of knockdown of CREBH on hepatocytes. Another set of hepatocytes was also transfected with an unspecific shRNA (Ad-USi) as a control. After co-culture with H/R-treated MCs, western blotting showed that Ad-CREBHi treatment significantly reduced CREBH protein levels in hepatocytes, as well GRP78 protein levels in MCs (P < 0.05, Figure 2e, f).

Analyses of GRP78 and CREBH genes using reverse transcription-polymerase chain reaction

Relative expression levels of GRP78 mRNA in the MCs + H/R and MCs + Tm groups were significantly higher than those in the MCs group (all P < 0.05). Furthermore, relative GRP78 mRNA expression levels in the L/M + H/R group were significantly higher than those in the MCs + H/R group (P < 0.05). However, there was no significant difference in GRP78 mRNA levels between the L/M + H/R and L/M + TM groups (Figure 3a, b). CREBH mRNA expression levels in the L/M + H/R and L/M + Tm groups were significantly higher than those in the MCs group (both P < 0.05). Moreover, GRP78 and CREBH mRNA expression levels were decreased using Ad-CREBHi, but not using Ad-USi (Figure 3c, d).

Figure 3.

Relative GRP78 and CREBH mRNA expression levels using RT-PCR. a: RT-PCR results of GRP78 in the MCs + H/R, MCs + Tm, L/M + H/R, L/M + Tm, and untreated control groups. b: Relative GPR78 mRNA expression levels in the L/M, L/M + H/R, and L/M + Tm groups. c: RT-PCR results of GPR78, CREBH-FL, and CREBH-N using Ad-CREBHi and Ad-USi. d: Relative CREBH mRNA expression levels CREBH-FL and CREBH-N with Ad-CREBHi and Ad-USi. Note *P < 0.05 vs the control group.

Tm: tunicamycin, H/R: hypoxia/reperfusion, MCS: myocardial cells, L/M: lower compartment and hepatocytes, Ad-USi: adenovirus for the unspecific, Ad-CREBHi: adenovirus for cyclic AMP-responsive element-binding protein H (CREBH) RNAi.

Effect of MC–hepatocyte co-culture on the viability of MCs

The results of the CCK-8 test showed that after H/R treatment, the viability of MCs in the MCs + H/R group was significantly lower than that in the MCs group (P < 0.05). Further, the viability of MCs was even lower in the L/M + H/R group than in the MCs + H/R group (P < 0.05). Nevertheless, treatment with Ad-CREBHi improved the viability of cells (Figure 4a, b).

Figure 4.

CCK-8 test of the viability of MCs. a: Viability of MCs in the MCs + H/R, MCs + Tm, L/M + H/R, L/M + Tm, and untreated control groups. b: Viability of MCs with Ad-CREBHi and Ad-USi. Note: *P < 0.05 vs the control group.

Tm: tunicamycin, H/R: hypoxia/reperfusion, MCS: myocardial cells, L/M: lower compartment and hepatocytes, Ad-USi: adenovirus for the unspecific, Ad-CREBHi: adenovirus for cyclic AMP-responsive element-binding protein H (CREBH) RNAi.

TNF-α and IL-6 levels in the MCs + H/R group were significantly higher than those in the MCs group (both P < 0.05), which suggested that inflammatory factor levels increased with an increase in the extent of myocardial injury. As expected, secretion of TNF-α (Figure 5a) and IL-6 (Figure 5b) was significantly upregulated by co-culture of hepatocytes and MCs in the L/M + H/R group compared with that in the MCs + H/R group (all P < 0.05). Moreover, administration of Ad-CREBHi normalized TNF-α and IL-6 levels.

Figure 5.

Detection of TNF-α and IL-6 levels using an enzyme-linked immunosorbent assay. a: Detection of IL-6 levels. b: Detection of TNF-α levels. Note *P < 0.05, **P < 0.01 vs the MCs group, #P < 0.05, ##P < 0.01 vs Ad-CREBHi or Ad-USi.

MCs: myocardial cells, H/R: hypoxia/reperfusion, Ad-USi: adenovirus for the unspecific, Ad-CREBHi: adenovirus for cyclic AMP-responsive element-binding protein H (CREBH) RNAi, TNF-α: tumor necrosis factor-α, IL-6: interleukin-6.

Effect of H/R treatment in co-cultured hepatocytes

To determine whether increased levels of proinflammatory cytokines promote CREBH expression, which may be required to activate the APR and cause ERS in hepatocytes, we performed reverse transcription-polymerase chain reaction (RT-PCR) analysis of co-cultured hepatocytes that were challenged with H/R. After 12 hours of H/R stimulation of MCs, mRNA expression levels of the endoplasmic reticulum chaperones GRP78 and C/EBP homologous protein (CHOP) were significantly higher in hepatocytes compared with the MCs group (controls) (all P < 0.05) (Figure 6b). Furthermore, CRP and CREBH mRNA levels were elevated in hepatocytes after H/R stimulation compared with controls (all P < 0.05). This result was confirmed using western blot analysis. We then studied single-cultured hepatocytes that were stimulated by IL-6 (60 ng/mL) or TNF-α (20 ng/mL). RT-PCR and western blotting results of GRP78, CHOP, CRP, and CREBH in hepatocytes are shown in Figure 6a, c, and d–f. In single-cultured hepatocytes, there was a significant elevation in the level of these four proteins compared with controls (all P < 0.05). These data provide evidence that proinflammatory cytokines in MCs can cause an UPR and APR activation in hepatocytes, as well as H/R-induced ERS.

Figure 6.

Effect of H/R treatment in co-cultured hepatocytes. a: Results of reverse transcription-polymerase chain reaction for GRP78, CHOP, CRP, and CREBH mRNA expression in hepatocytes stimulated by IL-6 (60 ng/mL) or TNF-α (20 ng/mL). b: Results of reverse transcription-polymerase chain reaction for GRP78, CHOP, CRP, and CREBH mRNA expression in hepatocytes after 12 hours of H/R stimulation in MCs. c: Western blotting results of GRP78, CHOP, CRP, and CREBH protein expression in hepatocytes. d: Fold activity of GRP78, CHOP, CRP, and CREBH protein expression in hepatocytes.

H/R: hypoxia/reperfusion, CRP: C-reactive protein, CREBH: cyclic AMP-responsive element-binding protein H, TNF-α: tumor necrosis factor-α, CHOP: C/EBP homologous protein

Discussion

Atherosclerosis is known as a chronic low-grade inflammatory disease.[19] Inflammation is generally believed to play a critical role in the pathogenesis of atherosclerosis.[20,21] Inflammation is considered to be the cause of proatherogenic changes in lipoprotein, including elevated very-low-density lipoprotein and decreased high-density lipoprotein cholesterol levels.[22] In the process of infection and inflammation, metabolic changes are caused by a complex systemic reaction called the APR. The APR leads to restoration of homeostasis and changes in the concentrations of specific plasma proteins, including CRP and serum P component of amyloid protein. We have previously studied the mechanism of injury caused by ERS-mediated inflammation in MCs after H/R. We found a role of nuclear factor-κB in the relationship between ERS and inflammation during myocardial I/R.[23,24] The relationship between myocardial I/R injury and the systemic inflammatory response was also shown by an elevation in plasma CRP and TNF-α levels after myocardial I/R injury.[5] Recent research suggests that CRP levels are not only an important indicator of the risk of myocardial infarction, but they also directly promote inflammation[25] related to myocardial I/R injury. This increases the myocardial infarct area and it can be mitigated with use of immunosuppressants, such as cyclophosphamide, methotrexate, and sulfasalazine. Moreover, inflammation is caused by different proinflammatory cytokines, such as TNF-α, IL-1β, and IL-6.[26] IL-6 levels are elevated in patients with ACS,[27] which might be attributable to secretion by the ischemic/reperfused myocardium.[28] Other cytokines may be released by monocytes.[29] Because of significantly increased serum levels of TNF-α or other cytokines, hepatocytes can respond to release of inflammatory cytokines and regulate transcription of the CRP gene, aggravating the systemic inflammatory response (Figure 5). Kaufman et al. found that CREBH was activated by ERS and released an N-terminal fragment from site-1 and site-2 proteinases. The N-terminal fragment can transfer to the nucleus to upregulate CRP expression.[6] However, there is lack of evidence regarding a direct association between liver-specific expression of CREBH and H/R-induced myocardial inflammation during the APR.

The hepatocyte-specific bZIP transcription factor CREBH can be cleaved by ERS, providing important signals that are necessary for the APR.[30] In the absence of ERS, CREBH remains in an inactive state as a 75-kDa full-length protein in the membrane fraction. CREBH is activated by the Golgi local proteinases site-1 and site-2 proteinases to release a 50-kDa N-terminal fragment. This fragment can migrate into the nucleus and induce transcription of APR genes, such as CRP and serum P component of amyloid protein. This provides a connection between ERS and the acute inflammatory response.[6,31,32] In our study, the role of ERS-mediated inflammation in MCs was studied during H/R. Our findings suggested that ERS contributed to myocardial I/R injury and increased the levels of various proinflammatory cytokines. Our experiments on the effect of CREBH cleavage on co-cultured MCs suggested that myocardial injury was more severe in co-culture of MCs and hepatocytes compared with cultured MCs alone, as shown by lower cell viability and higher proinflammatory cytokine levels. Proinflammatory cytokines might have an effect on MCs and hepatocytes, resulting in an increase of injury in MCs (Figure 4). Furthermore, western blotting and RT-PCR analyses indicated that CREBH cleavage may attenuate myocardial injury by activating the transcription of specific APR genes in hepatocytes under ERS. In contrast, inhibition of CREBH decreased myocardial injury and proinflammatory cytokine levels. These findings are consistent with previous reports, which suggested that CREBH exerts a proinflammatory effect that induces hepatocytes to increase proinflammatory cytokine levels in supernatant.[6,31,33] This further confirms the importance of CREBH as a crucial link between ERS and the APR in vivo.

Although CREBH belongs to the CREB/ATF family, it plays a different role in ERS owing to its different modes of stimulation, tissue distribution, and response element-binding protein.[34] Therefore, CREBH cleavage cannot affect the typical UPR for expression of ER chaperone genes, but it can induce the APR by regulating specifically expressed genes in the liver.[35,36] Previous reports have suggested that promoting functional recovery of the endoplasmic reticulum might exert therapeutic effects as follows. Salubrinal, which is a phosphatase inhibitor, can protect cells from ERS-induced apoptosis by selectively inhibiting the dephosphorylation of eukaryotic translation initiation factor 2 subunit α, thus inhibiting protein synthesis and accumulation in the endoplasmic reticulum.[37] Additionally, vaticanol B, which is a chemical chaperone of resveratrol tetramer, inhibits the UPR and inflammatory response by stabilizing misfolded proteins, facilitating protein folding, and reducing the protein folding load.[38,39] However, the molecular mechanism underlying the role of CREBH in modulation of APR genes requires further investigation. In summary, our study suggests that CREBH exerts proinflammatory effects on the hepatocyte–MC transwell co-culture system and results in aggravation of myocardial injury through the APR, which is activated by cleavage of CREBH (Figures 2 and 3).

There is increasing evidence that atherosclerosis is a systemic disease because serum high-sensitive troponin T levels are increased in many patients with an APR.[28] This suggests that myocardial injury occurs via the APR because many proteins that are synthesized during this process increase the risk of atherosclerosis. Moreover, CREBH plays a major role in the relationship of myocardial I/R injury and the APR (Figure 6). Rational targeting may modulate the cleavage of CREBH or suppress the APR and reduce myocardial I/R injury in patients with ACS.