SIRT5-Related Desuccinylation Modification Contributes to Quercetin-Induced Protection against Heart Failure and High-Glucose-Prompted Cardiomyocytes Injured through Regulation of Mitochondrial Quality Surveillance

Abstract

Myocardial fibrosis represents the primary pathological change associated with diabetic cardiomyopathy and heart failure, and it leads to decreased myocardial compliance with impaired cardiac diastolic and systolic function. Quercetin, an active ingredient in various medicinal plants, exerts therapeutic effects against cardiovascular diseases. Here, we investigate whether SIRT5- and IDH2-related desuccinylation is involved in the underlying mechanism of myocardial fibrosis in heart failure while exploring related therapeutic drugs for mitochondrial quality surveillance. Mouse models of myocardial fibrosis and heart failure, established by transverse aortic constriction (TAC), were administered with quercetin (50 mg/kg) daily for 4 weeks. HL-1 cells were pretreated with quercetin and treated with high glucose (30 mM) in vitro. Cardiac function, western blotting, quantitative PCR, enzyme-linked immunosorbent assay, and immunofluorescence analysis were employed to analyze mitochondrial quality surveillance, oxidative stress, and inflammatory response in myocardial cells, whereas IDH2 succinylation levels were detected using immunoprecipitation. Myocardial fibrosis and heart failure incidence increased after TAC, with abnormal cardiac ejection function. Following high-glucose treatment, HL-1 cell activity was inhibited, causing excess production of reactive oxygen species and inhibition of mitochondrial respiratory complex I/III activity and mitochondrial antioxidant enzyme activity, as well as increased oxidative stress and inflammatory response, imbalanced mitochondrial quality surveillance and homeostasis, and increased apoptosis. Quercetin inhibited myocardial fibrosis and improved cardiac function by increasing mitochondrial energy metabolism and regulating mitochondrial fusion/fission and mitochondrial biosynthesis while inhibiting the inflammatory response and oxidative stress injury. Additionally, TAC inhibited SIRT5 expression at the mitochondrial level and increased IDH2 succinylation. However, quercetin promoted the desuccinylation of IDH2 by increasing SIRT5 expression. Moreover, treatment with si-SIRT5 abolished the protective effect of quercetin on cell viability. Hence, quercetin may promote the desuccinylation of IDH2 through SIRT5, maintain mitochondrial homeostasis, protect mouse cardiomyocytes under inflammatory conditions, and improve myocardial fibrosis, thereby reducing the incidence of heart failure.

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1. Introduction

Heart failure is a condition that leads to ventricular filling or impaired ejection function due to various organic or functional heart diseases, and it represents the end stage of various cardiovascular diseases, particularly those associated with diabetic cardiomyopathy. Thus, heart failure is referred to as “the last battleground of diabetic cardiovascular disease” in clinical practice [1]. In the past few decades, most research has focused on the maintenance of diabetic myocardial injury, cardiac hemodynamics, and regulation of the islet system. Diabetes in patients with heart failure has been shown to occur significantly earlier than in patients without coronary heart disease, hypertension, or diabetes. Myocardial fibrosis is vulnerable to factors such as oxidative stress, inflammatory response, mitochondrial energy metabolism disorder, and cellular aging [2]. As the main cause of ventricular remodeling [3], myocardial fibrosis can promote decreased myocardial compliance and impaired cardiac systolic and diastolic function. Ultimately, long-term volume or pressure overload can lead to heart failure. Thus, progression from diabetic cardiomyopathy to heart failure is accompanied by severe myocardial fibrosis or cardiac hypertrophy [4, 5]. As such, improving myocardial fibrosis has been shown to delay heart failure and improve heart function and has become a new approach for treating diabetic cardiomyopathy and heart failure [6].

Mitochondria, the energy metabolism centers of cells, produce energy through oxidative phosphorylation to meet the high energy needs of the heart [7, 8]. Many important physiological activities occurring in the heart, such as myocardial contraction and maintenance of intracellular homeostasis, require ATP [9–11]. Mitochondria have their own quality control system to maintain and restore structure and energy metabolism by regulating mitochondrial fission, fusion, biogenesis, and mitophagy [12, 13]. This surveillance system can protect mitochondria and cardiomyocytes from stress stimulation [8, 13]. Moreover, myocardial damage because of diabetic cardiomyopathy may be related to mitochondrial dysfunction caused by an imbalance in mitochondrial quality surveillance.

Therefore, normal cardiac physiological functioning requires intact and fully functioning mitochondria. Indeed, excessive production of mitochondrial reactive oxygen species (ROS) or damage to the myocardial antioxidant system is related to ventricular hypertrophy and wall remodeling, which can lead to myocardial fibrosis and heart failure. Studies have revealed abnormalities in the morphology and structure of myocardial mitochondria in patients with diabetes mellitus complicated with heart failure and diabetic cardiomyopathy. Moreover, mitochondrial membrane damage and structural abnormalities have been reported in canine models of heart failure. Decreased mitochondrial membrane potential, abnormal mitochondrial permeability transition pore (mPTP) opening, decreased ATP synthesis, and excessive ROS production have also been detected [14, 15]. Hence, conducting mitochondrial quality surveillance by targeting mitochondrial mass and homeostasis may be useful for inhibiting oxidative stress and inflammatory responses, thereby improving fibrosis [16]. Oxidative stress and inflammatory responses are important factors that induce myocardial fibrosis and often coexist at the same lesion site in various cardiovascular diseases [16, 17]. When a variety of cardiovascular complications or metabolic cardiomyopathy occur accompanied by acute or chronic myocardial injury, the immune system is activated, releasing numerous inflammatory factors that induce oxidative stress injury, activate myocardial fibroblasts, and cause abnormal collagen metabolism, myocardial cell necrosis, and tissue degeneration, thus ultimately leading to myocardial fibrosis and heart failure [18, 19].

Sirtuin 5 (SIRT5) is widely distributed in the nucleus, cytoplasm, and mitochondria. Although SIRT5 exhibits deacetylase activity, it can regulate lysine succinylation [20]. Through its N-terminal peroxisome localization signal PTS2, SIRT5 can enter peroxisomes to reduce intracellular H₂O₂ production, thus playing a major role in cell oxidation. Moreover, SIRT5 reportedly promotes desuccinylation as a protective mechanism in acute myocardial infarction [21–23]. Specifically, acute cardiac ischemia and hypoxia may upregulate the expression of SIRT5 through the PGC-1α/PPAR-γ pathway, leading to subsequent desuccinylation of key proteins involved in cardiomyocyte energy metabolism, thus exerting a protective effect on these cells [24]. Posttranslational modification of SIRT5 occurs primarily in the mitochondria. Also occurring within the mitochondria, NADP⁺-dependent isocitrate dehydrogenase 2 (IDH2) can affect the normal operation of the glutathione- (GSH-) related mitochondrial antioxidant system, including the activities of glutathione peroxidase (GPX) [25]. Moreover, IDH2 provides NADPH to glutathione reductase and thioredoxin reductase, thereby eliciting a regulatory effect to protect mitochondria from oxidative stress [26]. However, few studies have evaluated the regulation of SIRT5 and IDH2 succinylation in heart failure.

Quercetin is a flavonoid that is widely present in nature. Pharmacological studies have reported that quercetin can delay vascular endothelial functional damage and cardiac terminal damage [27]. Quercetin also has a regulatory role in the prevention of myocardial fibrosis [28] and can further regulate islet function. Moreover, we previously found that quercetin can regulate mitophagy and endoplasmic reticulum stress through SIRT1/TMBIM6, improve mitochondrial energy metabolism, and protect human cardiac myocytes [27]. However, the regulatory mechanisms underlying the effect of quercetin on SIRT5 succinylation and its protective effect on myocardial cells remain unclear. Therefore, we hypothesized that succinylation regulated by SIRT5 affects the metabolic growth of cells via mitochondrial quality surveillance and mitochondrial homeostasis. We found that SIRT5 deletion may lead to increased succinylation, which in turn affects cardiomyocyte activity and myocardial fibrosis.

2. Materials and Methods

2.1. Animals and Drug Treatment

All experimental procedures were performed in accordance with the NIH Guide for the Care and Use of Laboratory Animals and were approved by the Shandong University of Traditional Chinese Medicine Institutional Animal Care and Use Committee. Briefly, 30 male wild-type C57BL/6J mice (8-week-old) were obtained from the Experimental Animal Center of Shandong University of Traditional Chinese Medicine and randomly divided into three groups: (1) sham operation, (2) transverse aortic constriction (TAC), and (3) TAC+quercetin. The TAC+quercetin group was intraperitoneally administered with 50 mg/kg quercetin daily (Shanghai Yuanye Biotechnology Company, Shanghai, China) for 15 days. Sham and TAC mice were administered with a corresponding intraperitoneal injection of normal saline.

2.2. Establishment of the Animal Model

A congestive heart failure model was established using TAC [29]. Briefly, the mice were anesthetized by intravenous injection of pentobarbital (50 mg/kg; Sigma-Aldrich, St. Louis, MO, USA), and a ventilator was connected after which thoracotomy was performed. The aorta was ligated with an 8-0 silk thread between the right artery and left common carotid artery and reduced to 25–30% of the original cross-sectional area with a 27 G needle.

2.3. Cell Culture

HL-1 myocytes were provided by the Experimental Center of Shandong University of Traditional Chinese Medicine. The cells were cultured in a Claycomb medium containing 10% fetal bovine serum, 100 U/mL penicillin/streptomycin, 0.1 mM noradrenaline, and 2 mM L-glutamine. The cells were cultured at 37°C and 5% CO₂ [30]. Glucose was purchased from Sigma-Aldrich. Quercetin was obtained from Shanghai Yuanye Biotechnology Company. The cells were randomized into the four experimental groups: (1) control, (2) high glucose (HG), (3) HG+quercetin, and (4) HG+quercetin+si-SIRT5. HL-1 cells were treated with high glucose (30 mmol/L) and quercetin (150 mg/L). For small interfering RNA (siRNA) transfection, Lipofectamine RNAiMAX (Invitrogen, Carlsbad, CA, USA) was used to transfect 50 nM siRNA into the HL-1 cells 24 h before treatment. All siRNAs were obtained from Jikai Biology (Shanghai, China).

2.4. Flow Cytometry

To analyze the apoptosis level, HL-1 cells were resuspended in phosphate-buffered saline (Gibco, Grand Island, NY, USA), fixed with 70% ethanol for 24 h, washed, and then placed in 50 μg/mL propidium iodide solution. After 30 min, the cells were resuspended, and flow cytometry was performed to detect apoptosis as described previously.

2.5. Cell Viability Assay

The viability of HL-1 cells was evaluated using an MTT assay. Cells were seeded into 12-well plates at a density of 50,000 cells/well. After 22 h, the cells were supplemented with fresh growth medium and incubated for 24 h, after which cell viability was determined by MTT assay [31].

2.6. Enzyme-Linked Immunosorbent Assay

An enzyme-linked immunosorbent assay (ELISA) kit was used to quantitatively analyze the activity of antioxidant enzymes and inflammatory factors in mouse myocardial tissue homogenates and HL-1 cells. Briefly, myocardial tissue homogenates and HL-1 cell suspensions were collected.

2.7. Oxygen Consumption Rate

The oxygen consumption rate of HL-1 cells in different groups was measured using a Seahorse XF Cell Mitochondrial Pressure Test kit (Agilent Technologies, Santa Clara, CA, USA), whereas the extracellular acidification rate was measured with a Seahorse XF glycolysis rate assay kit (Agilent Technologies). Both assays were performed according to the manufacturer’s instructions.

2.8. Real-Time Quantitative PCR

Total RNA was extracted using TRIzol reagent, and RNA integrity was analyzed by agarose gel electrophoresis. First-strand cDNA was synthesized using an iScript™ cDNA synthesis kit (1 μL of total RNA; Bio-Rad, Hercules, CA, USA) in a total volume of 20 μL. A CFX96 RT-PCR system (Bio-Rad) was used to analyze the level of cDNA twice using $500\times {10}^{-9}\text{nM}$ specific primers. In each experiment, continuously diluted mixed cDNA was used to evaluate the efficiency of the PCR analysis. Gene expression was quantified relative to the geometric mean of housekeeping gene expression amplified in the same sample as the studied gene, and gene expression was determined using the $2^{-\Delta \Delta \text{CT}}$ method [32].

2.9. Statistical Analysis

Data are expressed as the $\text{mean}\pm \text{standard}\text{deviation}\text{of}\text{the}\text{mean}$. One-way analysis of variance was used to verify the differences between multiple groups, and Student-Newman-Keuls post hoc test was performed. Two-tailed $t$-tests were used to compare two groups. Statistical analysis was performed using SPSS 22.0 software (SPSS, Inc., Chicago, IL, USA). Statistical significance was set at $P<0.05$.

3. Results

3.1. Quercetin Alleviates Myocardial Hypertrophy and Cardiac Dysfunction after TAC

C57BL/6J male mice were randomly divided into three groups (control, TAC operation, and TAC operation+quercetin). Quercetin was administered to the TAC+quercetin group (50 mg/kg, every 12 h). Seven weeks after TAC, approximately 20% of the mice in the TAC model group and 10% of in the quercetin treatment group died. Compared with that in the sham operation group, cardiac function in the TAC group deteriorated remarkably after 3 weeks (Figures 1(a)–1(i)). However, cardiac function in mice treated with quercetin was improved compared to mice not treated with quercetin (Figures 1(a)–1(i)).

[figures omitted; refer to PDF]

We then assessed myocardial hypertrophy in TAC mice after TAC+quercetin treatment using hematoxylin and eosin, WGA, and TUNEL staining 8 weeks after TAC (Figures 1(j)–1(m)). Compared with that in the sham operation group, the degree of cardiac hypertrophy and cardiomyocyte hypertrophy or death in TAC mice was significantly increased (Figures 1(j)–1(m)); however, this effect was significantly decreased following quercetin treatment (Figures 1(j)–1(m)).

3.2. Quercetin Attenuates Myocardial Fibrosis and Inflammatory Levels after TAC

We detected collagenase I levels in the myocardium of different groups by immunohistochemistry. The collagenase I/III level in the myocardium of the model group was significantly increased after TAC (Figures 2(h)–2(j)); this effect was reversed by quercetin (Figures 2(h)–2(j)). We also assessed the degree of myocardial fibrosis in different groups by Masson staining. The degree of myocardial fibrosis in the model group was significantly increased after TAC; treatment with quercetin reversed this phenomenon and protected the myocardial tissue (Figures 2(a) and 2(b)).

[figures omitted; refer to PDF]

Myocardial fibrosis is a complex pathological process primarily caused by long-term pressure overload and inflammatory reactions. Many proinflammatory factors, such as TGF-β, TNF-α, IL-13, IL-18, and MMPs, can participate in myocardial fibrosis. Hence, we detected the abundance of select proinflammatory factors (TNF-α, IL-13, and IL-18) by ELISA, while transcription levels of TGF-β and MMP-9 were detected by RT-PCR. The expression levels of TNF-α, IL-13, and IL-18 and mRNA levels of TGF-β and MMP-9 in the model group were higher than those in the control group (Figures 2(c)–2(g)). Quercetin reversed this phenomenon and inhibited inflammation (Figures 2(c)–2(g)). To verify whether the therapeutic mechanism of quercetin is related to SIRT5 and IDH2, we detected the mRNA and protein expression of SIRT5 and IDH2. The mRNA and protein expression levels were significantly inhibited after TAC (Figures 2(m)–2(p)). Quercetin reversed these effects, indicating that quercetin targets SIRT5 and IDH2 to protect against myocardial fibrosis and heart failure (Figures 2(m)–2(p)).

To further verify the protective mechanism of quercetin on myocardial fibrosis or myocardial injury after TAC, we investigated ROS production in the myocardial tissue and found that it was significantly increased after TAC (Figures 2(k) and 2(l)), whereas quercetin inhibited ROS overproduction (Figures 2(k) and 2(l)). These findings suggest that the protective effect of quercetin on myocardial fibrosis or myocardial injury is related to the regulation of redox homeostasis.

3.3. Quercetin Reduces High-Glucose-Induced HL-1 Inflammation Injury by Regulating Oxidative Stress

The aforementioned experimental results preliminarily showed that quercetin can improve cardiac function and inhibit the level of myocardial fibrosis in mice after TAC. Its protective effect might be related to the regulation of SIRT5 and anti-inflammatory factors; however, whether these events occur through a direct regulatory mechanism remained unclear. To study the regulatory mechanism of quercetin under high-glucose conditions, we induced HL-1 cell injury by high glucose, treated these cells with quercetin, and knocked down SIRT5 with siRNA. Cell activity was detected using the MTT and CCK-8 assays, apoptosis levels were detected using flow cytometry, and superoxide dismutase (SOD), GSH, TrxR, and malondialdehyde (MDA) activities were detected using ELISA. We used CCK-8 to analyze the viability of HL-1 cells under different glucose concentrations. As shown in Figure 3(j), cell viability decreased significantly at a high-glucose concentration of 30 mM. MTT and flow cytometry revealed that high-glucose conditions inhibited cell activity, increased apoptosis and ROS production, and accelerated cell death (Figures 3(a)–3(e)). Compared with that in the control group, high-glucose stimulation increased MDA activity and inhibited the activity of antioxidant enzymes, such as SOD, GSH, and TrxR (Figures 3(f)–3(i)).

[figures omitted; refer to PDF]

Quercetin inhibited the activity of MDA, increased the activity of SOD, GSH, and TrxR (Figures 3(f)–3(i)), inhibited apoptosis and ROS production (Figures 3(a)–3(e)), and improved cell activity (Figure 3(c)). However, si-SIRT5+quercetin treatment further enhanced the activity of MDA, increased the level of apoptosis and ROS production, and inhibited cellular activity (Figures 3(a)–3(i)). Collectively, these results demonstrate that quercetin regulates the imbalance in the redox state stimulated by high glucose and protects HL-1 cardiomyocytes. This regulatory effect may be directly related to SIRT5.

3.4. Quercetin Reduces High-Glucose-Induced HL-1 Inflammation Injury by Promoting SIRT5-Related Desuccinylation Modification

Oxidative stress directly affects the structure and function of myocardial cells and can directly activate the signaling molecules associated with myocardial fibrosis, such as MMPs, leading to hypertrophy and apoptosis of myocardial cells, which is related to excessive production of ROS, accompanied by an inflammatory reaction. Excess ROS production can damage mitochondrial macromolecules at or near their formation sites. Mitochondrial structural damage and functional collapse in heart failure are related to increased levels of ROS, primarily manifested as increased mitochondrial lipid peroxide and decreased enzyme activities of mitochondrial respiratory complexes I, III, and IV. However, energy metabolism in mitochondria is regulated by succinylation. Previous experimental results established that the therapeutic effect of quercetin on myocardial fibrosis and heart failure is related to SIRT1.

In the current study, analysis of the mRNA levels of SIRT5 and IDH2 in high-glucose-stimulated HL-1 cells and immunoprecipitation showed that IDH2 expression in HL-1 cells was significantly inhibited following high-glucose stimulation, whereas the succinylation level of IDH2 was significantly increased (Figures 4(a)–4(d)). Moreover, following quercetin intervention, the mRNA expression of SIRT5 and IDH2 and level of IDH2 desuccinylation increased (Figures 4(a)–4(d)). To further verify the effect of SIRT5-mediated succinylation on the mitochondrial respiratory chain, we assessed mitochondrial respiratory complexes I, III, and IV. After high-glucose stimulation, the levels of these complexes were decreased; however, quercetin reversed this phenomenon (Figures 4(e)–4(g)).

[figures omitted; refer to PDF]

The regulatory effect of quercetin on the mitochondrial respiratory complex and IDH2 succinylation were also inhibited following si-SIRT5 treatment (Figures 4(a)–4(g)). Therefore, SIRT5-mediated desuccinylation of IDH2 may be an important regulatory mechanism of myocardial fibrosis and heart failure. Moreover, quercetin may improve the inflammatory response and oxidative stress injury through SIRT5-mediated desuccinylation of IDH2; however, the regulatory mechanism of mitochondrial homeostasis requires further analysis.

3.5. Quercetin Reduces High-Glucose-Induced HL-1 Inflammation Injury by Regulating Mitochondrial Energy Metabolism and NLRP3

Mitochondrial energy metabolism is regulated by succinylation. However, heart failure or myocardial fibrosis caused by various factors involves an important pathological mechanism of oxidative stress and mitochondrial energy metabolism disorder in the inflammatory state. Therefore, we verified the regulatory effects of quercetin on mitochondrial energy metabolism and homeostasis. Immunofluorescence analysis showed that NLRP3 was highly expressed after high-glucose stimulation, which was reversed by quercetin (Figures 5(f) and 5(g)). Moreover, si-SIRT5 treatment eliminated the regulatory effect of quercetin on NLRP3 (Figures 5(f) and 5(g)).

[figures omitted; refer to PDF]

Regulation of mitochondrial homeostasis is closely related to NLRP3 activation. In fact, NF-κB can limit activation of NLRP3 by eliminating damaged mitochondria [33, 34]. We found that quercetin affected mitochondrial homeostasis by regulating NLRP3. High-glucose-stimulated HL-1 cells exhibited serious disorders of mitochondrial energy metabolism. The ATP level, basal respiration, maximal respiration, and respiratory reserve of mitochondria were significantly reduced. Moreover, the mPTP opening was abnormally increased (Figures 5(a)–5(e)). Quercetin reversed these effects and restored mitochondrial energy metabolism and mPTP closure (Figures 5(a)–5(e)). However, si-SIRT5 treatment reversed the regulation induced by quercetin on mitochondrial energy metabolism and mPTP (Figures 5(a)–5(e)). Therefore, excess production of ROS accompanied by inflammation and oxidative stress can lead to mitochondrial oxidative stress injury, and NLRP3 can interact with mitochondrial energy metabolism. Mitochondria may be the “Trojan horse” of inflammation, which is consistent with the results of a previous study [35].

3.6. Quercetin Reduces High-Glucose-Induced HL-1 Inflammation Injury by Regulating Mitochondrial Quality Surveillance

Mitochondria can alter their shape and size through quality surveillance mechanisms and generate new mitochondria through biosynthesis; thus, the mitochondrial pool is supplemented and the energy metabolism that needs cells under various conditions is met. Mitochondrial quality surveillance is critical for cytoprotective regulation during heart failure and myocardial fibrosis [36]. To explore the regulatory mechanism of quercetin on mitochondrial quality surveillance, we evaluated the mRNA levels of Drp1/Fis1 and Mfn1/Mfn2 after 24 h of high-glucose stimulation. Gene expression analysis showed high-glucose stimulation upregulated Drp1 and Fis1 and downregulated Mfn1 and Mfn2 in mitochondria (Figures 6(a)–6(d)); moreover, quercetin reversed these effects (Figures 6(a)–6(d)). We also evaluated mitochondrial biogenesis. qPCR analysis results showed that, after high-glucose stimulation, the expression of Tfam and PGC1α was severely reduced. In turn, quercetin increased the levels of Tfam and PGC1α and enhanced mitochondrial biogenesis (Figures 6(e) and 6(f)). It is worth noting that mitochondrial fission was increased significantly following si-SIRT5 treatment, whereas mitochondrial biosynthesis was decreased (Figures 6(e) and 6(f)). Thus, the ability of quercetin to regulate mitochondrial quality surveillance may be closely related to SIRT5.

[figures omitted; refer to PDF]

The results showed that the protective effect of quercetin on HL-1 cells was closely related to its regulation of mitochondrial quality surveillance. Quercetin may promote the desuccinylation of IDH2 through SIRT5, thereby maintaining mitochondrial respiratory chain function and mitochondrial homeostasis, subsequently improving cell activity.

4. Discussion

Myocardial fibrosis is closely associated with heart failure and is characterized by dysregulated extracellular matrix metabolism and collagen component ratio. It is caused by oxidative stress damage and inflammation induced by heart failure [37]. Oxidative stress and inflammatory cytokines can cause mitochondrial homeostasis disorders, affect the posttranslational modification of related proteins, cause damage to the contractile function of cardiomyocytes, and induce cardiomyocyte fibrosis, leading to heart failure [38]. Hence, a better understanding regarding the role of mitochondrial function and protein posttranslational modification in myocardial fibrosis injury will provide insights into myocardial remodeling from the perspective of mitochondrial quality surveillance and oxidative stress, while also providing new strategies for improving the prognosis and treatment of heart failure. Specifically, targeted drugs for mitochondrial quality surveillance are urgently needed [39]. In this study, we found that the level of myocardial fibrosis in the mouse myocardium and myocardial cells increased after surgery, whereas the cardiac ejection function decreased. Moreover, quercetin can regulate myocardial cell mitochondrial homeostasis after stress injury, inhibit oxidative stress damage and inflammation, maintain cardiomyocyte activity, and reduce myocardial fibrosis damage in mice with heart failure. Quercetin can also protect myocardial tissue, increase the expression of SIRT5 in cardiomyocytes, and promote IDH2 desuccinylation.

The primary cause of death in diabetic patients is cardiovascular diseases; however, the importance of heart failure in diabetic patients is not yet fully understood. Furthermore, the relationship between these two conditions is not solely at the level of comorbidities, rather an intricate relationship exists resulting in their reciprocal promotion or suppression [40]. Additionally, indicators that are reflective of insulin resistance, including glycosylated hemoglobin (HbA1c), fasting blood glucose, and insulin levels, are related to the risk of heart failure. Additionally, a series of physiological or metabolic abnormalities, including autonomic neuropathy, microcirculation dysfunction, changes in metabolism or energy, and increased accumulation of advanced glycation end products, may cause insulin resistance or cardiomyopathy in diabetic patients [41].

Moreover, heart failure can increase the risk of insulin resistance, impaired glucose tolerance, and diabetes. Long-term abnormal carbohydrate and lipid metabolism or enhanced fatty acid metabolism and increased oxygen consumption further induce dysfunction of the mitochondrial respiratory chain of cardiomyocytes, resulting in a sharp decline in mitochondrial energy metabolism, which indirectly leads to imbalanced redox homeostasis and the overexpression of inflammatory factors [42]. Specifically, diabetic cardiomyopathy is a type of diabetes complicated by a vascular disease. Utilization of glucose metabolism by myocardial cells in patients with diabetes and heart failure accompanied by myocardial ischemia and hypoxia is reduced [43, 44]. The results of this study also indirectly established that a high-glucose environment can indirectly lead to mitochondrial quality surveillance.

In an oxidative stress environment, the oxygen and blood supply of cardiomyocytes is significantly reduced, resulting in production of a large amount of oxygen free radicals and a variety of intermediate metabolites. It can also cause a metabolic imbalance in the body, damage the myocardial cell membrane, and disrupt the balance between extracellular degradation and synthesis [45, 46]. Proliferation of myocardial fibroblasts leads to myocardial fibrosis, which in turn causes a large amount of intercellular collagen to be deposited and cell structure to become disordered, effectively disrupting the balance between various types of collagen. Hence, severe myocardial fibrosis has been shown to ultimately lead to heart failure. Although most previous studies have focused on the role of quercetin in oxidative stress and inflammatory damage [47], it can also regulate mitochondrial homeostasis, expression of related proteins, and posttranslational modifications [48]. Our results expand on these previous findings that suggest quercetin functions through SIRT5 to promote the desuccinylation of IDH2, thus regulating mitochondrial homeostasis, protecting the activity of myocardial cells, and improving the damage associated with myocardial fibrosis. Hence, quercetin may represent a new therapeutic approach for treating heart failure.

In mice, mitochondrial homeostasis disorders or dysfunctions are primarily caused by overproduction of ROS and insufficient ATP synthesis, which adversely affect the structure and function of the heart, leading to subsequent heart failure [49]. Under conditions of oxidative stress and inflammation, excessive production of ROS can cause oxidative damage to cellular proteins, lipids, and mitochondrial DNA, as well as induce cell damage and apoptosis [50]. This is largely due to the imbalance in mitochondrial homeostasis caused by disruption of redox homeostasis associated with inflammation. Currently, many studies have indicated that the inflammatory response that occurs when heart failure occurs is closely related to oxidative stress [51]. The onset of heart failure is accompanied by severe myocardial hypertrophy and myocardial fibrosis. As far as the pathological mechanism of heart failure is concerned, when myocardial infarction occurs, factors such as myocardial ischemia, hypoxia, impaired mitochondrial function, and activation of neutrophils and inflammatory factors cause an explosive increase in ROS. This excess production of ROS caused by an imbalance in redox homeostasis is then accompanied by NF-κB activation and subsequent activation of proinflammatory gene promoters in monocytes. Consequently, inflammatory factor transcription is upregulated, and the NADPH oxidase complex is oxidized on the cell membrane to generate ROS, inhibiting the activity of antioxidant enzymes and further stimulating the occurrence of inflammatory reactions [52]. This vicious circle is an inducing factor for the progressive aggravation of myocardial hypertrophy and fibrosis. ROS can also damage actin and excitatory-contractile coupling proteins, resulting in cardiac muscle systolic/diastolic dysfunction. Moreover, insufficient ATP synthesis leads to a lack of energy supply to cardiomyocytes, which has serious adverse effects on cardiomyocyte survival and cardiac ejection function [53].

In addition, severe diabetic cardiomyopathy with heart failure is accompanied by myocardial hypertrophy, partial myocardial ischemia, and hypoxia [36, 53]. The energy metabolism of myocardial cells is converted from fatty acid oxidation to glycolysis to adapt to hypoxia as a self-protective mechanism. However, this conversion is accompanied by a desuccinylation modification. In this study, we found that high-glucose stimulation can lead to apoptosis or death, which may be caused by the interaction between oxidative stress and the inflammatory reaction. This reaction is also accompanied by an imbalance in mitochondrial energy metabolism and mitochondrial quality surveillance. Similar to hypoxia/ischemia, a high-glucose environment can induce excessive ROS production, resulting in oxidative stress and mitochondrial mass imbalance. Consequently, glucose metabolism disorders further aggravate the primary cardiovascular disease or microcirculation damage, which may represent a key mechanism associated with diabetes mellitus complicated with heart failure.

IDH2 participates in the tricarboxylic acid cycle by catalyzing the conversion of isocitrate to α-ketoglutarate and NADP⁺ to NADPH. Studies have reported that knockout of IDH2 in mice can lead to a decrease in the redox state of NADPH and thioredoxin reductase activity in mitochondria. It can also lead to decreased cell activity and mitochondrial oxygen consumption [54]. Moreover, knockout of IDH2 decreases NADPH levels and mitochondrial GPX activity in mice with hepatic ischemia-reperfusion injury, leading to mitochondrial cristae loss, mitochondrial fragmentation, mitochondrial fissure shift, cytochrome c release, and cell death [55]. A lack of IDH2 can also lead to increased mitochondrial ROS, inhibited histone deacetylase activity, and increased activation of NF-κB through acetylation, leading to increases in inflammation and apoptosis [56]. Indeed, IDH2-deficient mice exhibit accelerated heart failure, increased apoptosis and hypertrophy, and mitochondrial dysfunction, which is related to an imbalance in redox homeostasis [57]. Our results are consistent with those of previous studies, indicating that mitochondrial homeostasis and quality control disorders of murine cardiomyocytes are related to the succinylation of IDH2.

Succinylation of lysine is a recently discovered protein posttranslational modification in which a lysine (K) residue in the protein is converted from the succinyl group by succinyl-coenzyme A [58, 59]. Related in vitro and in vivo studies have shown that quercetin can significantly reduce AngII-induced myocardial contractility, fibrosis, inflammation, and myocardial hypertrophy while inhibiting the expression of fibroblast differentiation markers type I and type III collagen [28]. Quercetin also reverses isoproterenol-induced cardiac hypertrophy by restoring the cellular redox balance and protecting mitochondria [38]. Our results show that quercetin promotes the desuccinylation of IDH2 through SIRT5, regulates the redox balance, maintains mitochondrial homeostasis, inhibits inflammation, protects cardiomyocytes, reduces the level of myocardial fibrosis damage, and restores heart function. These findings are consistent with those of previous studies; that is, high-glucose stimulation causes an imbalance in redox levels, causes inflammation, and activates mitochondrial quality surveillance and homeostasis, as well as the mitochondrial apoptosis pathway. In addition, we show that SIRT5 promotes IDH2 desuccinylation, increases the sensitivity of cells to oxidative stress, and reduces oxidative stress damage to cardiomyocytes, which have also been observed previously [60].

Our study had three main limitations. First, although we conducted in vivo studies using animal models of heart failure and myocardial fibrosis to verify the regulatory effect of quercetin, but we did not conduct targeted verification using gene knockout animals. Second, only mitochondrial homeostasis, and not endoplasmic reticulum function, was evaluated. The pathological mechanism of myocardial fibrosis is primarily related to calcium homeostasis. The endoplasmic reticulum is an important intracellular calcium store. Excessive or low calcium levels in the endoplasmic reticulum can cause calcium signaling disorders, leading to abnormal physiological functions in cardiomyocytes and the occurrence of myocardial fibrosis. Third, the interaction between endoplasmic reticulum stress and mitochondrial homeostasis has not been clearly elucidated in the pathogenesis of diabetes mellitus complicated with heart failure; however, myocardial fibrosis was not examined. Despite these limitations, our research shows that quercetin can promote the desuccinylation of IDH2 through SIRT5. Quercetin maintains the regulation of mitochondrial homeostasis and redox balance, inhibits inflammation, and reduces the apoptosis level of cardiomyocytes, as well as the level of muscle fibrosis and recovery of cardiac ejection function.

5. Conclusions

Our results provide insights into the pathological mechanism and clinical treatment of myocardial fibrosis and heart failure. Heart failure is one of the most serious cardiovascular complications in patients with diabetes; however, currently, there are few drugs that can control blood sugar and improve myocardial damage in clinical practice, and the treatment and pathological mechanisms remain unclear. In this study, it was discovered through in vivo experimental studies that quercetin can effectively improve the pathological response of heart failure in mice after TAC, improve cardiac function, inhibit the expression of inflammatory factors and the level of myocardial fibrosis, and protect the myocardium. Furthermore, we showed that quercetin can regulate the redox balance of mouse cardiomyocytes under high-glucose conditions, inhibit the release of NLRP3 inflammasomes, regulate mitochondrial quality surveillance, maintain mitochondrial homeostasis, and inhibit the apoptosis or death of cardiomyocytes in high-glucose environments. In addition, the active ingredient quercetin as a natural medicine affects the SIRT5 regulatory mechanism by promoting desuccinylation. Quercetin can regulate the succinylation of SIRT5, which may improve the tolerance of mitochondria to oxidative stress and inflammation. We infer that quercetin, which has antioxidative stress effects, can regulate mitochondrial quality surveillance through the “inflammation-oxidative stress” pathway. Although there have been great advances in deciphering the pathological mechanism of the “inflammatory-oxidative stress-mitochondrial dysfunction” pathway, the associated crosstalk mechanism has not yet been fully elucidated. The results of this study suggest that quercetin may become a supplementary alternative drug or daily health supplement for patients with diabetes and heart failure; however, large-scale, multicenter clinical studies are needed to further verify its effectiveness and safety.

Authors’ Contributions

Xing Chang and Tian Zhang contributed equally to this work.

Acknowledgments

This study was supported by the Natural Science Foundation of Shandong Province (grant number ZR2020MH352) and the National Natural Science Foundation of China (NSFC; grant number 82004233). We would like to thank Editage (https://www.editage.cn) for the English language editing.

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