 Well, it's an enormous pleasure and honor to be here. I have many, many friends here. And as I mentioned yesterday, two things that probably mark my career as the greatest honors that I have received is that I am the chief of cardiology at UT Southwestern. And two chiefs ago, Dr. Willerson held that role. I'm the editor in chief of circulation, and two editors ago, Dr. Willerson was in that role. And I'm the proud holder of the James T. Willerson Distinguished Chair at Southwestern. So it's an honor to be here and to speak with you today. I'm going to talk about the past, the present, and the future. And for those of you who came to this talk yesterday, I will let you know that there are little places where you can check your email because there's going to be a little overlap here, some overlap. But I mentioned yesterday that communicable diseases, I'm going to try to use this thing here, have outstripped non-communicable diseases around the world, including in the developing world. As such, cardiovascular disease is the number one killer of men and women around the world. United States, one in four women will die of heart disease, one in four. Contrast that with breast cancer, which is one in four T, four zero. That is also true around the world, although as we'll see, the face of cardiovascular disease is different. And as Dr. Willerson mentioned, cardiovascular disease is a global problem. It knows no political boundaries. And that's why we have positioned circulation as a global journal. We are a high-volume journal. As you're aware, we get about 100 or 120 papers a week. We publish five or six of those. We have 50 editors. A third of them are in Dallas. A third are in the US outside of Dallas, including Beacon Boskert here. And another third are in countries outside the US and 15 different countries and in 10 time zones. And importantly, each of those editors has the same role on the leadership team. We don't have international editors. We have editors, whether they are in Dallas or Houston or New York or Paris or Uppsala or Tel Aviv, Singapore, Beijing or Santiago, they're all the same. And as Dr. Willerson mentioned, we meet weekly for two or two and a half hours in a video conference to discuss papers among ourselves. But let's look back in the past. This is ancient history. This is year 2000, 20 years ago. The number one killer of human beings on this planet was high blood pressure. If we lump tobacco and cholesterol together and call it atherosclerotic cardiovascular disease, that was the number two killer of Homo sapiens. If we jump over malnutrition and underweight, which is progressively becoming not much of a problem, in fact, just the contrary, the number three killer on this planet has been diabetes. And I will submit to you that number two is slipping down, thank goodness. And number three is rising such that those two will flip, that diabetes will be the number two killer of human beings in the coming years. This is what the present looks like. This is where cardiovascular disease lives. And you can see that, of course, orange and red are worse and you can see that cardiovascular disease is a scourge in the developing world, unlike the way it was 20 years ago. It is now spread around the world. So a moment of philosophy, if I may, we as physicians all see patients every single day to try to cure disease, that are to try to eliminate it from the patient's problem list. But in reality, there are quite few cardiovascular diseases that we can cure. In fact, there are not that many diseases in internal medicine that we can cure apart from infections and some cancers. So even though we try to cure diseases and we can cure Wolf Parkinson-White, we can cure AVNRT. Most of the time, we have to settle for the next best thing. If we can't cure a disease, as is typically the case, we generally have to settle for the next best thing, which is to turn an acute disease into a chronic disease that can be managed for decades. I told this story yesterday that when I was a medical student at Duke back in the 1980s, I sat in a first-year medical student in a large lecture hall, and I heard lectures about a syndrome that was emerging in Northern California and in Haiti where young men were having their immune systems just shut down. They developed unusual infections and unusual cancers and they died. Nobody had the first idea what it was, the cause was, but it was named the Acquired Immune Deficiency Syndrome, and if you got it, it was a death sentence. Now, some years later, we haven't cured HIV-AIDS, but as of 2017, 50% of people with HIV-AIDS are over 50 years of age. You can have HIV, if you're compliant with your medications, you can have HIV-AIDS for decades. Now, we haven't cured it, but it's been transformed into a chronic disorder. Let's look at how that appears in cardiovascular disease, for example, in hospital mortality from myocardial infarction. In the 1950s, prior to the advent of the Coronary Care Unit, if you had a heart attack in the hospital with a nurse standing beside you, there was a 30% chance you were not going home. If you had that MI in your living room, it was probably 60%, 70%, 80%. Then with the advent of the Coronary Care Unit, with the various things that we can do there, over the course of about 15 or 20 years, that mortality was cut in half. By the 1990s with anti-platelet therapy, thrombolytic therapy, percutaneous coronary intervention, it was cut in half again. Now, in 2019, in most hospitals in the US, and in Japan, and in Europe, in hospital mortality from myocardial infarction is 3%. It's been cut in half, and cut in half, and cut in half. We haven't cured atherosclerotic disease, but progressively, we are making progress of turning it into a chronic disorder that you can carry for a long time, and that disorder is called heart failure. I will submit to you that heart failure, in many ways, is the future of cardiovascular medicine. So let's step back. That's in hospital mortality from myocardial infarction. What about just cardiovascular mortality in general in this country? If I tell you that in the last 50 years, the acutely lethal manifestations of cardiovascular disease have changed in this country over the last 50 years. So age-adjusted mortality, take a 70-year-old man from 1960 and that same guy today, what is the likelihood that he will have dropped dead of cardiovascular disease? Has it gone up or gone down? How much? It's declined 75%. Spectacular, unbelievably robust success thanks to new devices and therapies and statins and of course lifestyle-related things related to blood pressure and smoking and exercise and diet and obesity and diabetes. We've seen dramatic successes. So all of these people that previously would have dropped dead are now surviving. They're returning to their families, to society, to the workforce. We haven't cured cardiovascular disease, but it's being progressively transformed into a chronic disorder that can be carried for a long time, which is, as I say, typically what we have to settle for. This same curve is shown here to illustrate that two things, that A, we almost crossed over with cancer. We almost became number two. But then seven years ago, that progressive improvement that we have seen for 50, 60 years stopped. It plateaued off for five years and the last two years, we're losing ground. We're backing up for the first time since 1960. We're backing up, we're losing ground. Nobody knows why, but I will submit to you that it's very likely that this is the form first of the manifestations of a global epidemic, especially here of obesity, metabolic dysfunction and diabetes. This, I fear, is the future of cardiovascular disease related to this metabolic stress. The face of cardiovascular disease looks different in other parts of the world. For example, in China, I have occasion to go to China regularly as part of my personal mission with circulation and the acutely lethal manifestations of STEMI and stroke are exploding in China. One of the hospitals that I collaborate with, Fuwai Hospital in Beijing, they do 100 PCIs a day, 100 PCIs a day, seven days a week. In India, where I just was two weeks ago, I believe that that is getting ready to launch, that is getting ready to start, that is now coming in to India, I will submit to you. So for the early career people in the room, I urge you to think about where cardiovascular disease is going. I hope you understand, I hope I've illustrated that 20 or 30 years ago, it looked very different. 50 years ago, it looked very different than it does now. Where will it go in the future? I fear that much of it stems from this. This is not Dallas, but it might as well be in Dallas. We have witnessed over the last 20 years a radical transformation of the populace of our nation. This is the prevalence of obesity with a B of I greater than 30 in 1994, where in most places it was in the range of 15% or less. Now, in many, many states it's over 30%. A dramatic change over the course of 25 years and where obesity is, where diabetes is, it has changed the face of our nation and it's changing the face of our profession, like this. And even though I'm not a native Texan like Dr. Willerson, but I've been here long enough to know that we've definitely got this. And it's not just in the United States. This has been in women, 1980 to 2008. This is obesity in North America. This is what we all know. This is obesity in China, B stage right there. In the United States, with this much obesity, the prevalence of diabetes is 14%, one four. In China, with this much obesity, the prevalence of diabetes is 14%, the very same number. A country of 1.4 billion people, diabetes affects 14%. The prevalence of pre-diabetes in China, again, a country of 1.4 billion, pre-diabetes 40%, 40%. This is what it looks like in South Asia and the Indian subcontinues. In both of these groups and these ethnic groups for reasons we don't yet understand, it takes much, much less obesity to trigger metabolic toxicity and diabetes than it does in the rest of the world. We don't understand why that is, but it's an urgent question. As I mentioned yesterday, as a Caucasian male here in the United States, I would probably have to carry 50 or 60, 70 pounds to be prone to diabetes. If I were a Han Chinese male, it would be 10 pounds. Nobody knows why. I can digress, there's lots of hypotheses around these. In both of those cultures over the course of centuries, they grew up in the context of malnutrition, of caloric deficit, and there's the notion of a thrifty gene such that these people in those two parts of the world tend to store obesity in a visceral distribution, which is unhealthy, that is maladaptive. And now that malnutrition is not an issue, in fact, it's the other way around, caloric excess, this thrifty gene is working against them. That is a hypothesis that is widely discussed. The other part of this future that we face is high blood pressure. This is hypertension in 2010. You can see that it is now everywhere. Literally billions of people have high blood pressure. And probably the majority of them don't know they have it. The ones that know they have it, a subset of them are on therapy, and the ones who know they have it and are on therapy, only a subset of them are controlled. Usually somewhere in the range of 10% are actually know they have it, are on therapy and are adequately controlled. It is a global catastrophe that is changing the face of our world. Again, this is the rapid, unbelievable expansion of diabetes in the United States. But this is a paper that was published in the Lancet about six months ago, and it shows the probability that a woman will die of a non-communicable disease before the age of 80. All the countries in the world, and you can see that is bad. The likelihood that a woman will die of a non-communicable disease before the age of 80 is shown there. This is every country in the world, and this is the likelihood, the height of the bar is the likelihood that a woman will die of a non-communicable disease. There's India. 50% chance, essentially, that a woman will die of a non-communicable disease there. They are actually making some progress, but they're not on track to achieve the World Health Organization goal of 30 by 30, 30% decline by 2030. They're making progress, they're not on target. This is China, about five points down, making progress, but not on target. We are down here, about 15 points lower, but we're making no progress at all. Which countries are leading, setting an example to us? Japan, South Korea, Spain, France, and Switzerland, right here. Amazing success in those countries. Who is suffering the most? Afghanistan, Yemen, and Africa. That's for women. This is men. Everything is about 10 points worse. Again, look at the likelihood of dying of a non-communicable disease in these various countries. Here's every country in the world, the likelihood that a man will die of a non-communicable disease by the age of 80. Here's India, 10 points worse than for women. Again, making some progress, but not enough. China is about five points down, but 10 points higher than for women. Here's the US. Again, consistently 10 points worse relative to women, but not making any progress. Who is leading the way? Once again, Japan comes in first. Iceland, Switzerland, Australia are doing spectacularly. The other end is North Korea, Moldova, and Mongolia. I started off by saying that non-communicable diseases have outstripped communicable disease around the world. What are these non-communicable diseases? What diseases are we talking about? Fucking heart disease. This cardiovascular disease that is affecting this scourge around the globe in both men and women. What do I think the future looks like? My friend and long-time mentor Eugene Braunmaul said the thrombo-cardiologists of the 20th century will be replaced by the diabetes cardiologist of the 21st century. I really think he's right. That we have, thanks to folks in this room and elsewhere, we've had spectacular successes addressing the thrombo-embolic manifestations of MI stroke and elsewhere. Although there's a lot of work to do in the developing world, this is where the future goes, is the diabetes cardiologist. Industry has picked up on this. I don't have to tell you that we have an armamentarium of 11 classes of drugs to treat high blood pressure. It's been this way for 70 years. Just in the last 10 years, the number of drugs to target diabetes has exceeded that. We have an incredible armamentarium now to treat diabetes. Industry has picked up on this and armed us with a tool chest that's enormously effective. In fact, some of these drugs, SGLT2 inhibitors, I submit will emerge as not diabetes drugs, but rather as heart failure drugs. The lines between endocrinology and cardiology are blurring around this. And I believe that more and more of cardiovascular medicine in endocrine context will be coming to us. We will have to become experts in diabetes, for example, in treating patients with some of these drugs that have profound effects in the heart. Mechanism, by the way, unknown. I'll tell you two little brief stories. This poor gentleman just had dinner and stepped out into the cold and dropped his cigarette right there, see? He's having a myocardial infarction. He's losing heart cells. And progressively, as he's standing on that sidewalk and makes his way to the emergency room, he's losing heart tissue. He's given beta blockers and oxygen and nitrates and morphine and he's taken to the cath lab where that coronary artery is open. Thereby salvaging myocardium, PCI salvage myocardium. Everyone here knows, of course, that the injury response is not aborted when you open up that infarct-related artery in the cath lab, it is just slowed and there is a second wave of injury, so-called reperfusion injury. If you have a heart attack, half of your injury derives from the ischemic phase and about the other half derives from the reperfusion phase. Same thing as stroke. If you think about the way in which we treat MI, everything we do targets this ischemic phase. We lower blood pressure, we lower heart rate, we lower DPDT, we do everything. The number of therapies we have to treat the other side, the other half is zero, zero. We have nothing to treat reperfusion injury. Same thing in stroke. And that's not for want of trying. People have tried for many years and a theme in my career has been that you'll hear now twice is that I'm a physician who does basic science and I believe that there have been many failings of the basic science community at targeting these sorts of things. There have been countless clinical trials that have failed in reperfusion injury that were based on one lab, one animal model, a small signal, and unbelievably, so often people will not do the critical experiment. They will load the animal up with drug and then injure it and measure infarct size. That's like treating Mr. Jones on Tuesday because you know he's gonna have a heart attack on Wednesday. It makes no sense clinically. Shockingly, so often people don't do that last experiment and that is to deliver the drug at the time where the patient and the healthcare system are interfacing, like in the cath lab. So a few years ago we started doing this and I will tell you that I won't show you the data but we studied this in mice and we found that by repurposing a class of drugs that are cancer chemotherapy agents that are quite easy to tolerate, so-called histone deacetylase inhibitors which we had studied in the context of autophagy, that if you deliver that to a mouse, an H-dac inhibitor, and give him a heart attack, the heart attack is about 40% smaller, big signal. Two other labs in this world saw the same thing so the signal was reproducible independently at three different places on this planet. We did the experiment where we would deliver the drug at reperfusion, in other words, when the patient is lying on the cath lab table, same thing, 40% cardio protection. We then, in a study we published a few years ago in circulation, did a clinical trial essentially in a large animal where we reversibly ligate the left circumflex coronary artery and we randomized animals to one of three arms, waited 24 hours, exposed them to 30 minutes of ischemia, reperfusion for 24 hours and we analyzed them by echo and necropsy. So first of all, some animals were pre-treated. They got a dose of drug here, a second dose, another just before surgery and another at reperfusion. This is where you load them up with drug and injure them to ask a biological question. The second arm is we gave them a dose of vehicle and a double dose of drug only at reperfusion. This is to answer a clinical question. Then the third arm is as a control we gave the animals vehicle only. Similar to what we had done in rabbits and mice and others. And I will tell you that we did this with the same rigor you would use in a human clinical trial where everyone was blinded to the treatment group, the people who were doing echoes and necropsy were blinded until the end of the study at which time we broke the code. And to make a long story short, we found that infarct size over the area at risk was decreased similarly, whether the drug was delivered pre-treatment or post-treatment, even though the area at risk, the surgeries were similar. The decline in contractile performance measured either as fractal shortening or EF, the decline in contractile performance was preserved even when the drug was delivered at the time of reperfusion. I've discussed this with the pharmaceutical industry many times and no one is willing to pull the trigger and pursue this because reperfusion injury has been a sore nerve in this industry for a long time. So I'm happy to tell you that we're planning to do this now in China that we have, I've approached some colleagues in Beijing and we actually formed a company over there and the first of all, the Chinese government made us re-synthesize the molecule for some reason and nobody understands why. They made us redo the mouse experiments again. This is now his fourth time and saw the same thing. And so we've reformulated this drug as an IV formulation and hopefully we'll start enrolling patients at Fulwai Hospital in the cath lab in the next few months. We're asking a biological question. We're not, this is not a multinational clinical trial to try and get FDA approval for a drug but rather to ask a biological question in the model we care about, which is people. I don't have to tell you that if you take a normal coronary in an animal and you tie it off with a suture, that's very different than a ruptured inflamed plaque in a patient with diabetes. It has just having a heart attack. They're just different. So whether this will work or not, I don't know. If it does, it will be, I think, a significant advance opening up the prospect of reperfusion therapy. I will tell you, we've gone back and we're currently doing these experiments in stroke in mice and we see the very same thing, actually, interestingly, the same cardioprotective response in stroke, although the mechanism is different, the H-dacs that are involved are actually different, interestingly. And I would submit, at least I did in a grant recently, that a small infarct might be something that you can get away with. A small stroke is another thing. A small stroke is probably much, much more morbid than a small infarct. But let me also talk about HEFPEF. This is something I'm super excited about. Another project, again, that I spoke about yesterday, that you're all aware that heart failure bends out as about 50% of individuals have a so-called reduced ejection fraction, which means less than 50%. Another half have a preserved ejection fraction. We used to call this diastolic heart failure. And HEFPEF exacts a huge toll on individuals and families and societies and healthcare systems around the world. It is an enormous, enormous problem. Importantly, it is not a my site only problem. It is a circulatory system-wide disorder that affects the entire circulatory system. In some individuals, they manifest with a largely renal phenotype or a pulmonary presentation and so forth. It is a heterogeneous disorder that affects the entire circulatory system. It has a two-to-one predilection for females. We'll talk about that again. Why is that? And importantly, HEFREF is getting better. We're seeing less HEFREF in this world. Thank goodness, HEFPEF is going up. In fact, it's thought that nowadays there's more HEFPEF in this world than there is HEFREF. For HEFREF, we have many drugs that we use every day, antitents and receptor blockers, ACE inhibitors, mineralocorticoid receptor antagonists, all of these drugs of which there are about six or seven classes that provide mortality and or morbidity benefit. We use them every day in HEFREF. Every single one of them has failed in HEFPEF. Every one, there has never been a positive clinical trial in HEFPEF. Even though HEFPEF is just as bad for you as HEFREF, just as mortal as HEFREF. Our toolbox to treat our patients with HEFREF is replete with numerous agents. We have drugs, antitents and receptor, neprolysin inhibitors, resynchronization therapy, mechanical circulatory support, cardiac transplantation. There are many things we can do for our HEFREF patients. Nothing for our HEFPEF patients, nothing. We have nothing. We treat comorbidities and we diarrhea some. It's incredibly frustrating and I know all of you are aware. So HEFPEF has been an elusive target now for many years. There have been many, many failed trials, including one just the other day at ACC. And again, I personally believe that some of this responsibility lies in the domain of the preclinical science where the literature in my mind is polluted with many different models of HEFPEF that don't look like patients with HEFPEF, that don't replicate the myriad complex clinical features that we see in human beings. There are models of diastolic dysfunction. That's not HEFPEF. There's models of temporary HEFPEF. Patients with HEFPEF don't, it's not a temporary thing, it doesn't devolve into HEFREF. So about three years ago, I recruited a postdoc to the lab, a cardiologist, MD-PhD cardiologist from Italy, and we sat down in my office and decided that this is incredibly frustrating as practitioners of this field in this field. And when we dig into the literature, it's shameful how many models of HEFPEF simply don't look like what we see in people. So we set out boldly to try to address that and recognizing the realities that I illustrated earlier that there are millions of people in this world with chronic control blood pressure and with diabetes. In fact, most patients with HEFPEF are obese with diabetes and have high blood pressure. So we very simplistically made a mouse that is obese with diabetes and has high blood pressure. Very simple thinking. Our notion was that it's a two-hit mechanism that pressure or mechanical stress from afterload, elevations and high blood pressure, coupled with metabolic stress, as we see in hundreds of millions of people, maybe that will lead to HEFPEF. That was a hypothesis. We decided to raise blood pressure by targeting endothelial enosynthes and enos using a molecule called L-name. We quite arbitrarily decided to raise blood pressure about 40 points or so and we exposed animals to a high-fat diet thereby leading to obesity and diabetes. So in other words, animals were exposed to two hits concomitantly, a mechanical stress and a metabolic stress. So what you'll see in subsequent slides is animals that were exposed to no hits, one hit alone, the other hit alone, or the two hits together. We'll take all four groups out five weeks and they will phenotype them extensively to see if they have HEFPEF. In some instances, you only need one hit to elicit a phenotype. You only need high-fat diet, irrespective of the presence of L-name, to render the animals obese and insulin resistant. It only takes that one hit. It only takes one hit of L-name, irrespective of high-fat diet to render the animals hypertensive, most systolicly and diastolic. Injection fraction is normal throughout in all four groups, no hits, one hit, second hit, both hits. However, global longitudinal strain measured by speckle tracking echo is uniquely suppressed in animals exposed to two hits, which is exactly what we see in people. They have unequivocal contractile dysfunction, but to the extent that echo can't pick it up, that's what we see in people. They have diastolic dysfunction, uniquely in the animals exposed to two hits, both measured noninvasively and by invasive pressure measurements. Animals have a modest hypertrophic response, but importantly, they have heart failure. They have exercise intolerance and pulmonary edema, only in the animals exposed to two hits. They have a modest hypertrophic response, a modest fibrotic response, which is what we see in people. They have microvascular dysfunction, measured as coronary flow reserve in the LAD, uniquely in the animals exposed to two hits. They have a modest capillary rarefaction response. If you isolate my sites and measure contractile properties in isolation, you can see that both systolic and diastolic properties are abnormal. So after about a year of this, working on this 12-point or so checklist, that we decided we had to see, before we would say that this model replicates what we see in patients with Hefev, we decided now about two years ago that we think this is a model that in my opinion is more informative than any model I personally have seen in the literature. These animals have the comorbidities that we see in people. They have the contractile abnormalities that we see in people. They have bona fide, heart failure, and they have the cellular and molecular abnormalities that we see in patients. This model, I will humbly submit, replicates the human circumstance better than any model I've seen in the literature. So now, two years ago, we decided we're gonna go and try to glean underlying mechanisms of this syndrome. One of the areas we looked at first is evidence of protein misfolding. You may know that protein misfolding is a hallmark of many, probably all forms of heart disease. Cardiac myocytes are post mitotic, right, some of these they don't divide. They divide once after you're born and then that's all you get for the rest of your life. And so those cells have to process proteins pretty carefully. It's not like if you, as they say, if you live in a small apartment, you have to take out the trash pretty regularly. These cells can't replicate, so they have to maintain their proteins and other things in a very regulated way, arguably more so than a non-post mitotic cell. So protein misfolding is a hallmark of a sick cardiac myocyte. Let me introduce this so-called unfolded protein response, which is an evolutionarily conserved response to protein misfolding. It is, all eukaryotics, organisms all the way back to yeast have an unfolded protein response. In mammals, it consists of three arms that I'll discuss, but let me simplify it by saying that if you have too much unfolded protein, the first thing the cell does is make less protein. It elicits new chaperones to try to fold those proteins. It elicits a degradation response in both the ER and in the cytosol. And if that fails, it commits suicide. It kills the cell to preserve the organism. This protein misfolding is a highly toxic signal in a cell and the cells, all our cells, have evolved a beautifully multi-dimensional strategy to target that. One arm of this, so there are three arms. There's PERC, IRV1-ALPHA, and ATF6. This arm here is the most evolutionarily conserved one. You might think of it possibly as the most important one. In yeast, there's only this arm here. Goes like this, IRV1-ALPHA, and basically this protein here, BIP, is glommed onto these three things, shutting them off, but if they're misfolded proteins, that pulls BIP off and activates these three arms. In this arm, IRV1-ALPHA is an enzyme, it's an endonuclease that cleaves RNA. It splices a molecule called XBP1, leading to XBP1 spliced, which is a transcription factor that turns on a bunch of genes. We have studied this in other contexts. For example, we published a paper a few years ago, where in the setting of myocardial infarction, we find that this pathway is activated, turns out that XBP1-S, a transcription factor, directly transcriptionally activates four enzymes in the hexosomene biosynthetic pathway, and that is a cardioprotective thing. So in that paper, we pulled together these two worlds of the unfolded protein response and the hexosomene biosynthetic pathway, and we found that they're linked, conferring a substantial cardioprotective response. So we've actually studied this pathway in a number of other diseases. Here in MI, it's turned on. In high blood pressure, it's turned on. In diabetes, it's turned on. In every disease we've ever looked at, the unfolded protein response, this active, this arm, XBP1-S arm is turned on. Still here. For the first time ever, we've found that this pathway, using multiple different strategies of evaluation, is turned off. It is down-regulated. It's turned on if you have only one hit. It's turned on if you only have the other hit, as I mentioned, but if you have the two hits together, it's turned off. It's down-regulated across the board, multiple ways of evaluating that. If you isolate adult mouse ventricular myocytes, it is down-regulated there, and our enzyme here that cleaves IRV1-alpha, or XBP1, is down-regulated. This is a very surprising finding. Almost shocking. So I got on the phone with a colleague, a friend of mine, David Cass at Johns Hopkins. Turns out at that institution, they routinely biopsy Heffref and Heffpeff patients. And I said, David, could you please look at the abundance of the XBP1-S in your samples of human Heffpeff? I didn't tell him what the answer was, but I said, could you just please tell me what XBP1-S is doing in those endomyocardial biopsy samples? Same thing. XBP1-S is uniquely suppressed in human Heffpeff relative to Heffref, which is stable or maybe just a hair activated. So that was our first reality check to suggest that what we're seeing, in fact, is real, that it has bearing in the human circumstance. So reassured by that, we've motored on what happens if you have two little XBP1-S, let's put it back. Let's put XBP1-S back exclusively in cardiac myocytes, only in cardiac myocytes. In a context like this, if this is not familiar to you, suffice it to say that if you put doxycycline in the drinking water, the transgene is off, the transgene is off. If you remove doxycycline, it turns on and you express 10x levels you can put it right back into the cardiac myocytes. It works just fine. So with this in hand, we gave these animals Heffpeff for five weeks and then for the next two weeks, all while they're exposed to these stresses here, we restored XBP1-S levels and then phenotyped them. The diastolic dysfunction improved. Animals began to rot again. The pulmonary congestion resolved. Amazing. Two weeks of restoring XBP1-S in the cardiac myocytes completely turned this Heffpeff phenotype around. I should tell you that this paper, by the way, was published on Wednesday of this week, this is the day. So why is XBP1-S down? Why is it down? We don't know. We know very little bit of mechanisms of the syndrome, but one thing that is commonly bandied about in this syndrome is the notion of inflammation. Obese tissue is inflamed. Obese people have a chronic systemic inflammatory activation. That nowadays is called meta-inflammation, metabolism-related inflammation, meta-inflammation. And one of the hallmarks of that is an up-regulation of one of the N-O synthases called inducible NOS, INOS, goes up. We found a paper where people, another group, not us, studying obese liver found the very same thing. They found that the unfolded protein response is down-regulated and INOS is through the roof. It's up 10-fold. That enzyme is turned on and it makes so much N-O that the organism is flooded with N-O, which covalently couples to many, many, many different proteins. Dozens and dozens of proteins now are covalently coupled to nitric oxide, which does a whole host of things. In some cases, it leads to its degradation. It turns off the enzymatic activity. We don't know, including our friend IR-E1-alpha is S-nitrosylated. And these investigators posited that this overabundance of N-O leads to a covalently linkage to IR-E1-alpha, crippling it and preventing it from splicing XBP1. Knowing with this in hand, we asked that same question in our animals and we found that sure enough INOS is up six or seven-fold in these hearts and in these myocytes, it's on here somewhere, and in the cardiac myocytes. It goes up a little bit with one hit, a little bit with the other hit, but when you bring the two hits together, it goes up five or six-fold. And in fact, IR-E1-alpha is S-nitrosylated and crippled. I got on the phone with my friend David again. I said, David, could you please look to see what INOS does in patient samples of heff-pheff and what IR-E1-alpha has done? And he found the very same thing. INOS is up about five X in human beings with heff-pheff and IR-E1-alpha is S-nitrosylated and crippled. So the next reality checks that what we're seeing in people are being replicated. And what we see in our animals here is there's so much N-O that many, many, many proteins are covalently altered and crippled by this S-nitrosylation event. So then we ask, can we link these two things together? Is there a mechanistic link? So we engineered a virus to make INOS. It makes, works just fine. We can make plenty of protein. We can make plenty of transcript. We can make plenty of N-O. So if you take this virus and you put it on heart cells in a dish, you can see initially XP-P1-S goes up as a stress response, but once there's enough N-O to cripple IR-E1-alpha, it drops down close to zero. What does this do in vivo? So we gave animals heff-pheff and then we expose them for three days to a selective INOS inhibitor. Remember I told you we're using L-name to raise blood pressure. L-name doesn't touch INOS by about a 20-fold excess and then INOS goes up another fivefold. So it's two logs less effective. So we're not touching INOS with L-name, but rather we can use a selective compound to do that. It works just fine. N-O levels go way down. EF is normal, but you can see that diastolic dysfunction improves, measured non-invasively, and the animals start to run again. We did the same experiment genetically where we inactivated the gene coding for INOS. Same thing. INOS knockout mice don't develop heff-pheff because they don't have this up-regulation of INOS. So again, this story now was published earlier this week in Nature, and here is our model. We believe that a two-hit mechanism of mechanical stress and metabolic stress coupled together leads to a meta-inflammation response, up-regulation of INOS, flooding the organism, flooding the patient with N-O, which cripples many proteins, including I-R-E-1-Alpha and XP-P1-S. We've worked out the downstream events, but I don't have time to show those today. They're not reported in that paper, but let me make a couple of points. Many of the clinical trials targeting heff-pheff, they've all failed. Many of them target the renin, angiotensin, and aldosterone axis, and our evidence would suggest that that pathway is not a major player, so that might help explain why those trials have failed. Perhaps even more informatively, many of the trials have tries to raise N-O, using N-O donors like Sildenafil, and Isosorbide, and Nitroglycerin. And if you look at those trials, those patients who got the N-O donor, not only did they not get better, they actually got worse. And now we understand why. There's not too little N-O. There's way too much N-O. We had the arrow pointing in the wrong direction before. Number two, I mentioned that there's a two-to-one predilection for females in this syndrome, so we've done experiments in female mice where we've exposed them to this heff-pheff stress, and asked the question, is the female heart predisposed to extra heff-pheff, extra bad heff-pheff? And in fact, it's not. If anything, it looks to be a little bit protected like the female heart is to other forms of disease. If we remove the ovaries from those female mice, they behave like males. So our evidence would suggest that the female heart is not uniquely predisposed to heff-pheff. What then is the explanation? I don't have an explanation. I can tell you what is a possibility. I personally think it's likely that an arbitrary cutoff of 50% as an EF divider is ridiculously oversimplified. That you'd use that number in a 90-pound woman and a 300-pound NFL linebacker. We all say 50% is the right answer. I think that's very likely to be an oversimplification. Women tend to be physically smaller than men, and I think it's possible, and I'm not the only one, that an EF of 51 or 52 is not preserved, but rather is reduced in a woman. Hypothesis. The other hypothesis that might contribute to this is women live 10 years longer than men, statistically. So they're exposed to these two stressors for a longer period of time. I personally think that that is a leading explanation. It's a demographic explanation and not a biological explanation. The last thing I will tell you in this part, then I'm gonna bring it home with a couple more things, is that if you take a heart, as you probably know, that a heart still has to eat substrate all the time. It only has enough ATP in its gas tank for 10 heartbeats. If it stops eating, you get 10 heartbeats and it stops. So it is consuming fatty acids or amino acids or glucose or ketone bodies, and Professor Tagmeyer is the world's expert in this, all the time, all the time. If you raise blood pressure on a heart, it will start using more glucose. If you expose it to a diabetic stress, it'll start using more fatty acids. So these poor hearts are being pulled in two different directions. They don't know which way to go. They're being told to use more glucose and use more fatty acids. And so they are, it turns out, they're a pitch that's serendipitously, that this experiment has, I guess, not been done before, as somebody told me. And so we look to see which one would win. Turns out that the mitochondria are disordered at a profound level. And very briefly, if we analyze the metabolic events occurring in those mitochondria, glucose utilization is largely normal. The electron transport chain is completely normal, but there is a surgical strike on two enzymes that are involved in fatty acid beta oxidation, where both of them are hyper-satellated. And the deacetylase that normally would strip that off is down-regulated, as is its cofactor, NAD. So it's 31 and NAD plus. If we replete these animals, we're feeding on these Hefev animals with an NAD, repleting molecule, you can buy at GNC or at Amazon.com and these animals get better. It's amazing, they get remarkably better. So somehow we don't understand, this plays a role, how these two biologies, the surfative NO and this metabolic defect, how they communicate with each other, we don't yet understand. So finally, let me just wrap this up by saying that cardiovascular disease has evolved dramatically over the last 20, 30, 50 years and it will continue to do so. I will submit to you that the plasticity of the heart related to all these different stresses is a fundamental part of this. The heart can grow and shrink under a variety of circumstances. It can grow under situations of normal stress. This is purely good for you. This physiological growth response, used to call this salance armstrong heart until we learned that that was multifactorial. There's one pathway that leads to good heart growth. There are about a half a dozen pathways that lead to pathological growth in the setting of disease related stress. This pathological hypertrophy, if that stress is persistent, it's such that the thick walled ventricle becomes thin walled, their narrow chamber becomes dilated and you get heart failure. I'll remind you that the heart can shrink quite a bit. And patients with suffered a spinal cord injury who relegated to bed rest, the heart will shrink to about 70% of its former mass and stop. The heart shrinks when it is unloaded in bed or when it's unloaded in outer space or when it's unloaded mechanically or in the setting of stress from, we have catabolic stress like in cancer. The heart shrinks 1% per week in outer space. The heart shrinks 1% per week in bed. You may remember those of you who are my age that when the Apollo moonshot, they would splash down in those capsules in the Pacific with those giant parachutes. The astronauts didn't stand up and walk out. They had to be carried out horizontally. Of course they'd lost a lot of volume but they'd also suffered an atrophy response. So now if you put somebody on the space station for six months, are you gonna send them to Mars and back? They're gonna come back with an unacceptably atrophied heart. So what are you gonna do about that? You're gonna trigger good growth. Anybody know what exercise triggers the most good heart growth? Answer is rowing. It is most isotonic and isometric. Crew athletes have the biggest hypertrophic, physiological hypertrophic responses. So there has never been a time where we have more tools at our disposal. This evolving challenge keeps morphing in front of us but this is the most exciting time ever to be in this field. CRISPR-Cas9 gene editing has already revolutionized the way in which we analyze and manipulate the genome in animals and in people. The day will come, I believe, for example, hypertrophic cardiomyopathy, probably before that, Duchenne's muscular dystrophy, where we will edit the genes of human beings to treat their disorders. There is work even in human context. This is a paper that, this is not that physicists who did the ethically ridiculous stuff in China a few weeks ago, but rather a study where people are in fact beginning to move toward manipulating the human genome. And that is, I think, the reality that we are going to face. It has to be obviously controlled under strict ethical standards, but this is our future. I will submit to you that in the next 20 years we will stop transplanting human hearts and we will start transplanting pig hearts and pig pancreases and kidneys and livers. The pig genome is full of retroviruses and people are busily snipping those out using CRISPR-Cas9 and at the same time rendering the pig genome humanized. So we will start raising pigs with a essentially human heart that I believe will help solve this unending problem of inadequate supply of donors. Atrial inflammation has been a problem that has been in a theoretical issue now for 20, 30 years across many forms of heart disease that ceased to be a theory about a year and a half ago with the publication of the Kanto's trial with a surgical strike on interleukin-1 beta leading to mortality benefit in patients with elevated Rizchi high sensitivity CRP and a dramatic improvement in lung cancer. Suddenly inflammation has become front and center and I've told you one story from our lab about inflammation in Hepha. Precision diagnostics is front and center now where we can take a cell and turn it into a stem cell and then turn around and make it into a heart cell or a kidney cell or a liver cell such that we can begin to move toward precision therapy. We can study patients' tissues in a dish. We can have Mr. Jones's heart cells here and Mrs. Smith's heart cells here and analyze their responses to a variety of manipulations. That is already well underway. Digital devices are emerging. I personally think there's a fair amount of hype around this but certainly with time we'll be able to use these, harness these data to answer important questions. There's already a, Google has made a contact lens that can sense your circulating glucose levels and signal to an app that says, you know, your glucose is out of control. Blockchain technology has been said though. The blockchain is the most evolutionary thing since the internet. It is a distributed encrypted way in which information, all of the human information will be available to all of us around the world on each of our cell phones. That coupled with 5G technology, well, I believe revolutionized the way we take care of patients, incredibly empowering and democratizing of the healthcare outside of the large medical centers but beyond that. Machine learning is already here. You're aware that many mammograms and chest x-rays are read by a machine before a human being looks at it. Of course, EKGs, ECHOs, we're this close to doing this with ECHOs. There is a literature that measuring heart rate variability in the NICU will help predict impending sepsis long before you witness anything in that neonate clinically. There are studies, we see these in circulation where a machine learning in the intensive care unit or in the emergency room can glean patterns that we as humans can't see. I think this is important for the future. Big data is again here already. Again, I will submit there's a fair amount of hype about this. I've heard analysts say that it doesn't matter how good your data are. My analytics can figure that out and I'm a little old school on that. My blood pressure cuff is off by 50 points. I don't think your analytics is gonna figure that out. So it's up to us to make sure that we phenotype these data and put good data in. And I think that these big data analytics will be incredibly powerful. Again, I've already mentioned that precision therapy, we do that every day in infectious diseases and in cancer, we don't do that much in cardiovascular disease. Everyone here who's wearing glasses, your glasses are precision to you. They don't work for anybody else. They work just for you. I think the day will come when our therapies will be similarly precise. I will submit that the day will come for cardiac regeneration. And again, I'm sitting in the room here with experts in this field, pioneers in this field, that by either taking a fibroblast and turning it into a cardiac myocyte has potential. There is a preclinical literature around this where rather than taking that fibroblast and backing it up into a stem cell and then turning it into a heart cell, taking it directly over as trans differentiation, tricking heart cells into returning into the cell cycle. Again, Dr. Martin here is a world leader in this space. I believe that that has enormous potential. The reversal of aging, the senescence biology of the myocardium is an interesting area. It's not just, I think, not just wear and tear on a heart that beats four billion times in your life, but rather a senescence biological event that may be targetable. Finally, one thing that I think for me is a big black box is the microbiome. Each one of us in this room has three kilograms of bugs in us, a bacteria in us, and every one of us has a different spectrum of bacteria. And they do important things. We publish a paper where investigators took a mouse and gave it a heart attack and saw this much injury. They took another set and they sterilized the gut and gave them a heart attack and the injury was worse. They then took those same animals that were sterilized and repleted the bacterial flora and the injury size went back down again. So somehow the injury response of the myocardium to a ischemic stress is informed from the microbiome. So unbelievable, we don't, underlying mechanisms are A, unknown and B, going to be fascinating. So let me just start by saying that heart disease has evolved, it will continue to evolve. It'll be in a different place in 10 years, 20 years, 30 years. The tools at our disposal are unprecedented. It's never, there's never been a better time to be in this field. The last thing, very last thing I'll say is that we as a profession are bankrupting our society, bankrupting our healthcare system. 43% of Medicare is cardiovascular and it's going up. That's true around the world. And we will always continue to do that. We'll always provide for these patients as their diseases evolve. But the solution to bending that cost curve is at the level of the spicket over here. It's the research that we're all involved in to try to understand how diabetes is toxic to the heart and so forth, so that we can not only improve the livelihood of our patients and of the world, but also stem this unremitting rise in healthcare expenditures. So with that, I will stop and I'll be happy to entertain questions. Thank you for your attention. Thank you.