key: cord-0988060-q0t9z6yz authors: Fernandez Rico, Carlota; Konate, Karidia; Josse, Emilie; Nargeot, Joël; Barrère-Lemaire, Stéphanie; Boisguérin, Prisca title: Therapeutic Peptides to Treat Myocardial Ischemia-Reperfusion Injury date: 2022-02-17 journal: Front Cardiovasc Med DOI: 10.3389/fcvm.2022.792885 sha: aea0eba8904bc696b535accc0468dd14be57193c doc_id: 988060 cord_uid: q0t9z6yz Cardiovascular diseases (CVD) including acute myocardial infarction (AMI) rank first in worldwide mortality and according to the World Health Organization (WHO), they will stay at this rank until 2030. Prompt revascularization of the occluded artery to reperfuse the myocardium is the only recommended treatment (by angioplasty or thrombolysis) to decrease infarct size (IS). However, despite beneficial effects on ischemic lesions, reperfusion leads to ischemia-reperfusion (IR) injury related mainly to apoptosis. Improvement of revascularization techniques and patient care has decreased myocardial infarction (MI) mortality however heart failure (HF) morbidity is increasing, contributing to the cost-intense worldwide HF epidemic. Currently, there is no treatment for reperfusion injury despite promising results in animal models. There is now an obvious need to develop new cardioprotective strategies to decrease morbidity/mortality of CVD, which is increasing due to the aging of the population and the rising prevalence rates of diabetes and obesity. In this review, we will summarize the different therapeutic peptides developed or used focused on the treatment of myocardial IR injury (MIRI). Therapeutic peptides will be presented depending on their interacting mechanisms (apoptosis, necroptosis, and inflammation) reported as playing an important role in reperfusion injury following myocardial ischemia. The search and development of therapeutic peptides have become very active, with increasing numbers of candidates entering clinical trials. Their optimization and their potential application in the treatment of patients with AMI will be discussed. According to the World Health Organization (WHO), cardiovascular diseases (CVD) are the number one cause of death worldwide representing 31% of all global deaths and 18.6 million lives per year (1). CVD's burdens are predicted by WHO to stay at the first rank until 2030 due to the aging of the population and the increasing prevalence of diabetes and obesity. Acute myocardial infarction (AMI) among CVD represents the first cause of mortality worldwide (15.9 million/year). Since more than two decades, myocardial ischemia-reperfusion injury (MIRI) has been investigated resulting in important progress in both the knowledge of the mechanisms underlying cell death and in improved interventional procedures. However, MIRI is still associated with significant mortality and morbidity since 30% of infarcted patients die and 25-50% of survivors develop heart failure (HF) representing huge societal costs. Furthermore, experts predict that the global burden of cardiovascular disease will grow exponentially over the next few years because of the increased prevalence of diabetes and due to the long-term effects of the current COVID-19 pandemic (2, 3) . AMI is a consequence of the complete coronary artery occlusion occurring at the site of a plaque rupture, exposing its inner core and thus promoting thrombus formation. Criteria for AMI (types 1, 2, and 3 MI) are based on the presence of a myocardial injury with clinical evidence of acute myocardial ischemia and detection of a rise and/or fall of cardiac troponin (cTn) values, associated with at least one of the following symptoms: myocardial ischemia, new ischemic electrocardiographic (ECG) changes, development of pathological Q wave, new regional wall motion abnormality or detection of a thrombus [see the universal definition (4) ]. For all types of MI, rapid restoration of blood flow in the ischemic myocardium leading to myocardial reperfusion, either by thrombolysis or angioplasty, has become the "cornerstones" of treatment for AMI (5, 6) . All recommendations agree that reperfusion therapy should be performed in patients within the first 12 h of infarction to limit infarct size (IS), improve survival and prevent post-ischemic HF (7) . However, sudden blood flow restoration leads to fatal damage to cardiac cells via the activation of various intracellular cascades (8) . Since the initial description of this phenomenon by Jennings et al. (9) near 40 years ago, our understanding of the mechanisms of reperfusion injury has increased considerably. The pathogenicity is linked mainly to regulated cell death (RCD) under the control of numerous biochemical and cellular processes such as a burst of reactive oxygen species (ROS), loss of ionic homeostasis, mitochondrial dysfunction, and inflammation (10) . Lethal reperfusion injury, additional to ischemic injury, culminates in apoptotic death of cardiac cells that were viable immediately before myocardial reperfusion. Because the adult heart fails to have quantities of endogenous stem cells for cardiac regeneration (11) , dead cardiomyocytes are lost forever. At the moment, no pharmacological treatment is available to prevent reperfusion injury (12, 13) . The mechanisms contributing to IR injury are multifactorial and highly integrated (10) . The existence of such mechanisms triggered by reperfusion and leading to deleterious side effects including cell death can explain the persistence of significant mortality despite early patient management and the development of chronic HF in a significant proportion of reperfused AMI (14) . Indeed, reperfusion triggers cascades of biochemical and metabolic events that aggravate changes generated during ischemia. Studies in animal models suggest that reperfusion lesions are responsible for 25 to 50% of the final IS (15) . Cells can die from accidental cell death (ACD) (such as necrosis), which is usually triggered by unexpected injury or attack, escaping from any controlled molecular mechanisms (16, 17) . Qualitatively, necrosis is the major mechanism of cardiomyocyte death during ischemia as a direct consequence of oxygen deprivation leading to severe injury. In contrast, during reperfusion, cardiomyocytes die from regulated cell death (RCD) mechanisms involving genetically defined effector molecules and precise signaling cascades such as apoptosis and necroptosis (8) . Characterized by cell shrinkage, chromatin condensation, and distinctive blebbing (budding) of the plasma membrane, occurs via the intrinsic (Figure 1 ) or extrinsic (Figure 2 ) pathways converging into Caspase-activation and DNA fragmentation as a common result (18) . Specific DNA fragmentation is mainly detected in the myocardium after reperfusion and not during ischemia, suggesting that its activation is specifically triggered at the onset of reperfusion, depending on the recovery of ATP production (19, 20) . This is supported by a major IS reduction observed after the administration of inhibitors of pro-apoptotic mediators at early reperfusion (21, 22) . Moreover, the gold standard of cardioprotection, ischemic postconditioning, inhibits apoptosis as does the ischemic preconditioning from which it is derived (23) (24) (25) . Cardioprotection results from anti-apoptotic strategies (18) such as peptides targeting the First Apoptosis Signal (FAS) death-dependent apoptotic receptor (26, 27) , or the mitochondrial permeability transition pore (mPTP) such as Cyclosporine-A (CsA) with however inconsistent preclinical and clinical results (28) . In cardiac pathology, necroptosis has been identified as a lytic form of RCD leading to the release of proinflammatory intracellular molecules (29, 30) . Even if necroptosis is morphologically similar to necrosis, this pathway could also depend on Caspase-8 activity and therefor, be pharmacological modulable (i.e., inhibited by necrostatin-1). Necroptosis is triggered by oxidative stress or TNFα (Tumor Necrosis Factor), FasL (FAS Ligand), and TRAIL (TNF-Related Apoptosis-Inducing Ligand) cytokines activating death receptors (Figure 3 ) (31) . Necroptosis is triggered only if Caspase-8, responsible for the cleavage of RIPK1 (Receptor-Interacting serine/threonine-Protein Kinase 1), is inhibited. Phosphorylated RIPK1 and RIPK3 together with MLKL (Mixed Lineage Kinase Domain Like Pseudokinase) form the necrosome leading to phosphorylation and oligomerization of MLKL, which translocates to the plasma membrane to induce membrane rupture (32) . Autophagy is an evolutionary process to maintain cell homeostasis based on the degradation of intracellular materials and components within the lysosomal compartment of eukaryotic cells (17) . Because of the elimination of misfolded/dysfunctional proteins or organelles, autophagy was believed to be a cytoprotective catabolic mechanism of substrate recycling for ATP generation and cell survival. Autophagy is activated by ATP-depletion and subsequent AMPK FIGURE 1 | Schematic representation of mitochondrial-dependent apoptosis and mode of action of the therapeutic peptides during MIRI. During acute myocardial ischemia-reperfusion injury (MIRI), reactive oxygen species (ROS) burst and mitochondrial Ca 2+ overload activate regulated cell death (RCD) resulting in apoptosis or necrosis through the mitochondrial permeability transition pore (mPTP) opening. Excessive ROS induced important changes in normal mitochondrial structure and function resulting in the disorder of mitochondrial metabolic function. Therapeutic peptides reducing intrinsic apoptosis during MIRI were highlighted in green: (1) Cyclosporine A (CsA), (2) Elamipretide, (3) Humanin, and (4) Tat-BH4. CypD, cyclophilin D; NNT, nicotinamide nucleotide transhydrogenase; FAO, fatty acid β-oxidation; Prx, peroxiredoxins; Gpx, glutathione peroxidase; GsR, glutathione reductase; Trx, thioredoxin; TrxR, thioredoxin reductase; GSH, glutathione; GSSG, oxidized glutathione; PNC, purine nucleotide cycle; tBid, truncated form of BH3 Interacting domain Death agonist; BAX, BCL2 associated X Apoptosis regulator; BAK, BCL-2 Antagonist/Killer 1; OMM, outer membrane, IMM, inner membrane. (AMP-dependent Protein Kinase) activation, calcium overload, and ROS, which are found during prolonged ischemia, IR, and HF (33, 34) . A high level of Beclin-1 is critical for early autophagosome formation and its activity can be reduced by BCL-2 (B-cell lymphoma-2) or BCL-XL (B-cell lymphoma extralarge). Beclin-1 is cleaved by Caspases, showing the existence of a crosstalk between autophagy and apoptosis (35) . More recently, autosis was described as a new form of autophagy responsible for continuous cardiomyocyte death in the late phase of reperfusion although cell death processes should be completed within 2 h of reperfusion (36, 37) . Necrotic cardiomyocytes in the infarcted area provide the main stimulus for post-infarction inflammatory response through the release of DAMPs (Damage-Associated Molecular Patterns) in concert with complement cascade and ROS activation, mobilizing the resident immune cells of the heart at the onset of AMI. Neutrophil infiltration, innate immunity activation as well as cell-mediated damage are pathological mechanisms of inflammation-related IR injury observed after MI as exemplified through experimental and clinical studies (38) . In the context of AMI, the pro-inflammatory response, rapidly orchestrated during ischemia to remove the necrotic cells and repair the infarcted myocardium, is exacerbated following reperfusion leading to cardiomyocyte death and MIRI within 6 h and 24 h post-reperfusion. TLR2, TLR4, TLR9 (Toll-Like Receptors) and NLRP3 in the NLRP3-ASC-Caspase-1 inflammasome contribute to this strong but short inflammatory burst following reperfusion through IL-1 (Interleukin-1), IL-6, and active Caspase-1 mediators via the NF-κB pathway (Figure 4 ) (39) . Inflammation is deeply involved in the pathophysiology of MIRI but also in fibrosis formation and in post-infarct remodeling leading to HF (40) . Because inflammation contributes to IS and cardiac remodeling, it is a major predictor of adverse events after AMI (41, 42) . Therapeutic Peptides as a Novel Approach for Treating MIRI? Important chemical development of solid-phase peptide synthesis allowed the rise of not only small but also larger Frontiers in Cardiovascular Medicine | www.frontiersin.org synthetic peptides. In this review, peptides will be defined as molecules containing no more than 30 amino acids, to discriminate them from proteins or antibodies, which constitute a large field within the pharmaceutical industry. Peptides are attractive therapeutic molecules based on their favorable pharmacokinetic profile, good solubility, low toxicity/mitogenicity, and furthermore due to the unlimited possibility of introducing modifications to improve their stability/binding affinity (43) . It is then not surprising that therapeutic approaches using peptides have become an emerging market in the pharmaceutical industry over the past decades and that today more than 60 peptide drugs are Food Drug Administration approved and that many more are studied in clinical and preclinical trials (44) . The global peptide therapeutics market accounted for $28.15 billion in 2019 and is expected to reach $66.76 billion by 2027 growing at a CAGR of 11.4% during the forecast period (45) . As a consequence, a large variety of bioactive peptides that target processes of apoptosis, necroptosis, inflammation, and autophagy in MIRI have been identified and characterized (46) . The next chapter will be focused on therapeutic peptides administrated at the onset of reperfusion (pharmacological post conditioning) which is the only relevant clinical application since pharmacological preconditioning is incompatible with AMI therapy. Furthermore, we have mainly focused on those validated in ex vivo and in vivo IR animal models. Apoptotic mechanisms are dependent on ATP production, which means that this mechanism is not activated in ischemic conditions but is specific to the reperfusion phase (19) . Indeed, apoptotic cascades pre-activate during ischemia are fully executed during reperfusion (DNA fragmentation) (47) . Accordingly, numerous in vivo studies have reported positive results for specific anti-apoptotic interventions as cardioprotective strategies against MIRI (22, 23, 26, (48) (49) (50) because apoptosis, through the intrinsic (mitochondrial) (17) and extrinsic (death receptor-dependent) (17, 26) pathways, is a reversible process and can be manipulated to allow cardiomyocyte survival during AMI. All therapeutic peptides described below are summarized in Table 1 including the used experimental conditions (doses, administration modes, animal models, and potent effects), and those evaluated in clinical trials are listed in Table 2 . The intrinsic or mitochondrial pathway is activated upon intracellular stress such as calcium overload or damaged DNA and is characterized by the irreversible permeabilization of the mitochondrial outer membrane under the control of proteins with BCL-2 homology domain and a transmembrane segment (111) . The formation of pores in the outer membrane by oligomerization of BAX (BCL2 associated X Apoptosis regulator) and BAK (BCL-2 Antagonist/Killer 1) is regulated by activating BH3-only proteins such as Bid (BH3 Interacting-Domain death agonist) and by sensitizers such as BAD (BCL2 associated Agonist of cell Death) that sequester the anti-apoptotic proteins (BCL-XL) previously bound to direct activators. Moreover, in addition to its activation by Caspase-8 or granzyme B, Bid is engaged in response to death receptor stimulation, allowing crosstalk between the intrinsic and extrinsic pathways (112) . The permeabilization of the outer membrane leads to the release of pro-apoptotic factors into the cytoplasm, endonuclease G that will cleave DNA (Caspaseindependent mechanism) or SMAC (Second Mitochondrial Activator of Caspases) and cytochrome C (CytC) inducing in fine DNA fragmentation and cell apoptosis (113) . Mitochondrial respiratory chain with reduced CytC leads to mitochondrial ATP synthesis dysfunctions and to the dissipation of the mitochondrial transmembrane potential ( ψm), which in turn triggers the opening of the mPTP (Figure 1 ) (114). mPTP is a protein complex whose molecular identity remains not fully elucidated. Several proteins have been reported to be part of this complex such as VDAC (Voltage-Dependent Anion Channel) located in the outer membrane and ANT (Adenine Nucleotide Translocator) spanning the inner membranes, whereas others are described as protein regulators, such as the mitochondrial matrix chaperone cyclophilin D (CypD) (114, 115). The mPTP formation and opening occur at the onset of reperfusion (116) upon (i) oxidative stress when the respiratory chain is suddenly exposed to oxygen, (ii) Ca 2+ ion accumulation due to rapid mitochondrial membrane potential restoration, and (iii) neutralization of acidic pH as H + ions compete with Ca 2+ ions that bind to the mPTP trigger site (117) . Furthermore, mPTP allows the passage of small molecules (<1.5 kDa) into the mitochondrial matrix (118) and will contribute to the permeabilization of the mitochondrial inner membrane. mPTP opening has been proposed as the key driver of MIRI because the concentration of the endogenous potentiators of the mPTP (e.g., calcium and ROS) increased during this phenomenon whereas inhibitors (e.g., Cyclosporine A) reduced IS (119). However, a major limitation of mPTP inhibiting is the lack of knowledge on mPTP-forming proteins and how they are activated by calcium and ROS. Cyclosporine A (CsA) is a natural cyclic 11-mer peptide, isolated from fungus Tolypocladium inflatum, widely used to downregulate immune system activity and therefore the risk of organ rejection after allogeneic organ transplant. CsA is able to block mitochondrial calcium efflux in isolated mitochondria and to inhibit the Ca 2+ -dependent mPTP opening in the inner membrane of heart mitochondria (120, 121) . CsA (122) and the analogs NIM811 (123) and Debio-025 (124) bind mitochondrial CypD, preventing the mPTP pore opening, and have been described as promising drugs for the cardioprotection against MIRI (Figure 1 ) (119) . Indeed, CsA has provided encouraging results in many animal IR models (51-58) (for details see Table 1 ) and also in a proof-of-concept study in patients (98) . More recently, large-scale clinical trials were performed to evaluate CsA long-term cardioprotective effects (CIRCUS, CYCLE, CYRUS) (99-101) ( Table 2) . Unfortunately, published results have shown no evidence of long-term protection, reduced mortality, or prevention of early multiple organ failure. The controversial findings obtained in clinical studies were attributed to the differences in CsA formulations since it is a class II compound with extremely low aqueous solubility (6.6 g/mL) and high lipophilicity (Log P = 3). However, even if both formulations have been described to have similar pharmacokinetics (125) , Sandimmune used in CYCLE and CYRUS trials did not show the expected efficacy previously reported in the proof-of-concept trial by Piot et al. (98, 100, 101) . The same negative results were obtained using CicloMulsion R , a lipid emulsion of CsA, in the large-scale CIRCUS clinical trial (99) . More recently, new formulations using PLGA-, squaleneor lipid-based nanoparticles were developed to increase cell permeability of the therapeutic CsA but no preclinical study was yet performed (126) (127) (128) . Also, combined administration of polymeric nanoparticles encapsulating CsA or pitavastatin (organic compound) targeting mPTP opening and monocytemediated inflammation, respectively, has been reported to be more efficient than a single administration of encapsulated CsA (129) even if CsA impacts per se the immune response after myocardial IR (130) . The small cell-permeable Szeto-Schiller peptide (also known as SS-31, MTP-131, Bendavia, or Elamipretide) was developed for targeted delivery of antioxidants to the inner mitochondrial membrane (131) . This 4-mer SS peptide can scavenge hydrogen peroxide or peroxynitrite and inhibit lipid peroxidation through its structural motif alternating aromatic residues and basic amino acids (Figure 1) . Therefore, this SS-31 peptide provides significant protection against MIRI as shown by higher contractile force levels as well as increased heart beating rates, and prevents myocardial stunning when administered upon reperfusion in the ex vivo guinea pig heart (59) . As a mechanism of action, SS-31 could interact with phospholipids (i.e., cardiolipin) on the inner mitochondrial membrane maximizing membrane shape to improve the electron transport chain function and minimize the production of mitochondrial-derived ROS (Figure 1) . Later on, Kloner and co-workers demonstrated that Elamipretide reduced myocardial IS in different IR models (60) . For example, post-ischemic Elamipretide administration decreases IS in an ex vivo guinea pig IR model in the same way as in the in vivo sheep IR model where it was infused during the last 30 min of ischemia. Surprisingly, the authors could not show any cardioprotection in an in vivo rabbit IR model. More recently, Allen and colleagues demonstrated that Elamipretide (10 µM) administrated at the onset of reperfusion in an ex vivo rat IR model can improve mitochondrial function by aggregating cardiolipin (61) . Based on these promising experimental data, a multicenter study (EMBRACE STEMI) was performed to evaluate Elamipretide as an adjunct therapy to percutaneous coronary intervention for STEMI. The drug injected to patients before reperfusion was safe and well-tolerated but not associated with a decreased IS as assessed by creatine kinase-myocardial band (CK-MB) quantification (97) . Humanin (HN) is a mitochondrial-derived polypeptide (24-mer) encoded by mtDNA that regulates mitochondrial functions under stress conditions and protects cells against various situations such as diabetes mellitus, cardiovascular and neurodegenerative diseases mainly through anti-apoptotic effects leading to sequestration of BAX and Bid (132) (Figure 1 ). Muzumdar and colleagues have shown a significant reduction in IS after an intracardiac administration of HNG (S14G-humanin with a point mutation) at the onset of reperfusion in mice subjected to MIRI. HNG cardioprotection was associated with a significant increase in AMPK and endothelial nitric oxide synthase phosphorylation as well as to attenuation of BAX and BCL-2 levels (62). Later, Thummasorn and co-workers have demonstrated on rats subjected to MIRI that administration of HNG 15 min before reperfusion decreased IS and arrhythmia (63). Sharp and colleagues confirmed these results in a large animal model of MIRI but these effects were abrogated when ischemic time duration was prolonged from 60 to 75 min (64). Thus, although HNG cardioprotection translates beyond different animal models, further clinical studies are needed to validate HNG therapy for a clinical application. Mitochondrial dysfunction and permeability mPTP opening are regulated in part by the voltage-dependent anion channel of the outer mitochondrial membrane (VDAC), which is itself controlled by pro-and anti-apoptotic BCL-2 family members (Figure 1 ) (133) . Based on this fact, Roberta Gottlieb's group designed a peptide corresponding to residues 4-23 of BCL-XL protein conjugated to the protein transduction domain of HIV TAT (TAT-BH4) to develop a cardioprotective therapeutic strategy (134) . Indeed, TAT-BH4 preconditioning attenuated CK release and reduced IS in IR rat hearts (15 min before I), demonstrating the role of mitochondria and pro-apoptotic BCL-2 proteins in the process of cell death. To develop a more physiological-relevant therapeutic application, our group has analyzed the effects of the BH4 peptide injected intravenously at the onset of reperfusion in an in vivo murine MIRI model. Among the four formulations of BH4 with various cell-penetrating peptides [CPP: Tat, (RXR)4, Bpep and Pip2b] tested, we observed a decrease of ∼47% in IS and ∼60% in apoptosis in vivo either with Tat-BH4 or Pip2b-BH4 when administered intravenously 5 min before reperfusion (65) . Hurt and co-workers have determined that TRPV1 (Transient Receptor Potential Vanilloid 1), a non-selective calcium (ion) channel activated in cellular pain insults including hypoxia, regulates mitochondrial membrane potential and MIRI (66) . By using an 11-mer peptide decoy V1-cal coupled to the Tat CPP (135) , the authors revealed a substantial reduction in IR injury by inhibiting the inducible calcineurin-TRPV1 interaction in an in vivo MIRI rat model. Viola and colleagues have tested an 18-mer peptide directed against the alpha-interacting domain (AID) of the alpha 1c subunit of L-type calcium channel vectorized by Tat (AID-Tat peptide), which has been shown to attenuate the increase in mitochondrial membrane potential and metabolic activity after activation of the channel (136) . Later, they showed that AID-Tat peptide was able to reduce IS in rat hearts exposed to IR injury ex vivo when administered immediately after reperfusion (67) . AID-Tat peptide was reported to significantly decrease IS and improve cardiac contractility up to 12 weeks post-MI in rats in vivo as a result of a decrease in metabolic demand during reperfusion. For several years, we and several other laboratories have confirmed that the death receptor-dependent apoptotic (or extrinsic) pathway is activated during IR injury (137, 138) since elevated FasL levels were found in the blood of AMI patients activating the FAS death-receptor pathway and triggers the downstream apoptotic signaling pathway (20) . DAXX (Deathdomain associated protein-6) protein acting as downstream FAS receptor adapter appears to play a key role in IR injury in various organs including the heart (50, 139, 140) . The different roles of the DAXX protein depend on its subcellular localization: (i) antiapoptotic in the nucleus and (ii) pro-apoptotic in the cytosol upon the Apoptosis Signal regulating Kinase 1 (ASK1)-shuttling triggered by various stimuli such as oxidative or ischemic stresses (141) . Therefore, we have focused on the development of a therapeutic peptide targeting the FAS:DAXX interaction as a new treatment against MIRI. We designed a 16-mer interfering peptide DAXXp by SPOT synthesis vectorized with the Tat CPP resulting in the conjugated Tat-DAXXp peptide (26) . Our study showed that Tat-DAXXp (1 mg/kg, i.v. 5 min before reperfusion) treatment resulted in 48%-decreased IS in a murine IR model when assessed after 24 h reperfusion. Tat-DAXXp cardioprotection was achieved through the inhibition of both extrinsic and intrinsic apoptotic pathways (Figures 1, 2 ) and the activation of pro-survival cascades. More impressively, Tat-DAXXp showed the same cardioprotection in a 6-month follow-up study using the same drug/ischemic protocol (27) . In brief, Tat-DAXXp treatment decreased by 70% plasma cTnI concentration and mortality assessed at 24 h post-MI, and furthermore, increased ejection fraction (24%) compared to the non-treated control group during the 6-month follow-up. At the end of the protocol, histological analysis revealed a 54%decreased left ventricular fibrosis content compared to nontreated mice. Remarkably, Tat-DAXXp was still efficient after a 30-min delayed administration after reperfusion showing a wide therapeutic time window of cardioprotection. In conclusion, targeting the extrinsic pathway with Tat-DAXXp peptide at the onset of reperfusion revealed potent upstream cardioprotection in a murine model of MIRI validating this peptide as a promising candidate for therapeutic application since it promotes both cell survival and improves cardiac contractile function. Annexin A1 (AnxA1) is a 37 kDa glucocorticoid-regulated protein known to regulate the termination of inflammation and to have a therapeutic potential in IR injury (142) . Its N-terminal peptide Ac2-26 was shown to bind the formyl peptide receptor (FPR) family which inhibits neutrophil adhesion, migration, and infiltration (81, 143, 144) . In 2001, the group of Perretti has reported that Ac2-26 (1 mg/kg, i.v.) administrated at the onset of reperfusion or during 60 min, revealed significant cardioprotection associated with lower myeloperoxidase activity and IL-1β levels a rat IR model (79) . More recently, Qin and coworkers have confirmed a significant reduction in inflammation (48 h post R) associated with decreased IS, fibrosis, and apoptosis (7-days post R) in a murine IR model (80) . In parallel, Perretti and colleagues worked on several longer and modified Annexin A1 peptides called AnxA1 2−50 , CR-AnxA1 2−50 (81) , and CR-AnxA1 2−48 (82) displaying cardioprotective properties leading to reduced IS and decreased systemic concentration of the Chemokine C-C motif ligand 5 in a murine IR model. Mechanistically, the three peptides act as new Lipoxin A4 receptor agonists impacting phagocyte responses resulting in protective actions. Knowing that also agonists of formyl-peptide receptorlike 1 displayed cardioprotective effects in IR models, Hecht and co-workers have developed the CGEN-855A peptide (83) providing cardioprotection in both murine and rat IR models and displaying anti-inflammatory activity as revealed by polymorphonuclear neutrophil inhibition. Based on the selectin binding sequence of EC-SEAL (145), Dehghani and colleagues have created the 7-mer DS-IkL peptide using the one-bead-one-compound combinatorial library to incorporate unnatural amino acids coupled to the negatively charged proteoglycan dermatan sulfate (DS) known to interact with P-selectin (84) . DS-IkL localized at regions of vascular inflammation can reduce IS and cTnI levels in a murine IR model. Mice treated with DS-IkL at the onset of reperfusion and additionally 24 h later showed reduced neutrophil extravasation, macrophage accumulation, fibroblast, and endothelial cell proliferation, and fibrosis compared to the non-treated mice. Ghrelin is an octanoylated, 28-mer peptide, which is mainly generated in the stomach and also in small amounts in other organs such as the heart (146). The first evidence of a cardioprotective effect of Ghrelin administered at the onset of reperfusion was obtained in an ex vivo rat model of MIRI showing the reduced myocardial release of lactate dehydrogenase (LDH) and myoglobin as well as the depletion of myocardial ATP (85) . In a IR mouse model, Ghrelin was reported to reduce IS and inflammation when administered for 3 days before AMI (147) . In a more relevant model of MIRI, Wang et al. showed that one-shot Ghrelin administration (8 nmol/kg, i.p.) at the onset of reperfusion protected the rat heart against IR injury by inhibiting oxidative stress and inflammation via TLR4/NLRP3 signaling pathway (86) . Obestatin a 23-mer peptide issued from the carboxyterminal part of proghrelin (ghrelin derives from the aminoterminal part of the same precursor) was reported to protect cardiomyocytes from MIRI in vitro and in vivo (87, 88, 148) . Obestatin administrated by local injection in the left myocardium at the onset of reperfusion was able to reduce IS by ∼24% in a rat IR model and to decrease mRNA levels of TNF-α, IL-6, ICAM-1, and iNOS in rat cardiomyocytes after reperfusion (87) . Nearly in parallel, Penna and colleagues observed a ∼50%-decreased IS after the administration of 75 nM Obestatin during the 20 first min of reperfusion in rats (88) . To our best knowledge, very few peptides were identified as therapeutic treatment inhibiting necroptosis. The only peptide recently reported is Nesfatin-1; a new energy-regulating peptide displaying a pivotal role in the modulation of cardiovascular functions and protection against MIRI (89) . A previous ex vivo study on rats revealed that Nesfatin-1 administration in the first 20 min of reperfusion decreases IS by the same extent as ischemic postconditioning through the activation of the pro-survival kinase ERK1/2 (91) . In a rat MI model, Nesfatin-1 intraperitoneal injection provided a 50% IS reduction associated with a reduction in Beclin-1 (autophagy) and Caspase-3 (apoptosis) expression. Later on, this group demonstrated that only a high dose of Nesfatin-1 (20 µg/kg) was able to inhibit the expression of RIPK1, RIPK3, MLKL, ROCK1, and ROCK2 proteins (necroptosis and necrosis) in the same rat IR model (90) . The anti-apoptotic and pro-angiogenic effects of erythropoietin (EPO) have prompted a growing interest as a therapeutic molecule for the treatment of AMI and HF. Despite promising results in animal MI models where EPO reduces IS and maintains ventricular function (149) , clinical studies have revealed controversial results and both safety and tolerability problems. In 2008, Brines and colleagues designed an 11-mer peptide issued from the helix B of the EPO receptor beta-common chain subunit (= helix B surface peptide, HBSP) (150) . In vivo studies in MI models have confirmed that HBSP protects the heart from ischemic damage in the same way as EPO (151) . Further on, Lin et al. demonstrated that HBSP pretreatment attenuated diabetic cardiomyopathy by inhibiting AMPK-dependent autophagy (152) . Another study reported that the protective effect of HBSP against IR injury (i.p. 90 µg/kg, 5 min before reperfusion) is based on its inhibitory effect on cell autophagy (92) . Furthermore, HBSP treatment in a hypoxia/reoxygenationinduced apoptosis model on H9c2 cells revealed an inhibition of the autophagy-related proteins (LC3II/LC3I) expression and an enhanced expression of phosphorylated phosphoinositide 3kinase (PI3K) (153) . Glucagon-Like Peptide 1 [GLP-1, also known as GLP-1 amide] was reported to exert biological actions in the cardiovascular system. Pharmacological postconditioning with GLP-1 has been found effective to reduce IS in vivo in rats subjected to IR (94, 154) . In isolated mouse hearts, administration of GLP-1(9-36)amide (0.3 nM) induced a 32% IS decrease associated with PI3K-protein Kinase B (PKB)/Akt-and ERK1/2-dependent mechanisms (155) . The (109) . Cardioprotection was observed with another agonist, Liraglutide, showing a reduced necrotic area (156) and improved left ventricular ejection fraction after PCI (157) . The mechanisms of action of the GLP-1 receptor agonist modulates myocardial metabolism and hemodynamic effects including peripheral, pulmonary, and coronary vasodilatation, mimicking ischemic preconditioning (158) . A recent clinical trial COMBAT-MI combining remote ischemic conditioning (RIC) and exenatide administration shows that neither RIC nor exenatide, or their combination, were able to reduce IS in STEMI patients when administered as an adjunct to primary percutaneous coronary intervention (110) . Apelin (APLN) is the endogenous ligand for the G-proteincoupled apelin receptor (APJ receptor) (159) synthesized as a 77-amino acid prepropeptide further processed into C-terminal fragments Apelin-36, Apelin-19, Apelin-17, and Apelin-13. The adipocytokine Apelin plays a critical role in cardiovascular hemostasis. Secreted in myocardial cells and coronary endothelium, its expression is increased during myocardial damage (160) . Since the lack of Apelin was reported to compromise functional recovery of the injured heart, Apelin and its derived peptides were administered as therapeutic molecules. Simpkin et al. demonstrated for the first time that pharmacological postconditioning with Apelin-13 and Apelin-36 peptides protects the heart against IR injury in vivo through the RISK pathway activation and by delaying the mPTP opening, resulting in a 43% and a 33%-decreased IS, respectively (161) . Additionally, Apelin-16 was shown to increase the contractility of reperfused rat hearts (ex vivo) via the activation of pro-survival kinases (PKC and ERK1/2) (162). In obese mice (High-fat diet model), pharmacological postconditioning with Apelin-13 was reported to decrease infarct size, prevent apoptosis and mitochondrial damage induced by IR injury (95) . A new endogenous ligand of the Apelin-APJ axis (Elabela also called Toddler or Apela) allowing to protect against IR-induced fibrosis, apoptosis, and oxidative stress via the PI3K/AKT signaling pathway has been identified (96) . The natriuretic peptide (NP) system consists of at least two distinct endogenous peptides: atrial natriuretic peptide (ANP) and brain (or B-type) natriuretic peptide (BNP). Due to the endocrine function of the heart, these peptide-hormones are secreted inducing specific signals via c-GMP coupled receptors. Besides different functions (e.g., lipolysis, lipid oxidation, mitochondrial respiration), NPs play an important role in cardiac vascularization reducing arterial blood pressure as well as sodium reabsorption (163) . NPs were recognized as cardioprotective compounds for MIRI in different animal models based on data showing that ANP administration reduced IS, increased blood flow, and decreased both left ventricular systolic and end-diastolic pressures in dogs subjected to myocardial IR (70) . More recently, IS reduction by ANP was confirmed by Asanuma et al. in a more severe IR dog model (71) . Similar results were obtained with BNP in a rat IR model showing reduced IS and decreased LDH and CK levels compared to untreated animals (74) . Thereafter, Li et al. using a recombinant BNP (RhBNP) demonstrated the attenuation of inflammatory infiltration and CD4+ T cell proliferation function in addition to IS reduction (75) . In 2003, hANP treatment was reported to limit IR injury on a small cohort of 19 AMI patients (164) . The subsequent study revealed that an ANP infusion during >48 h allows preventing LV remodeling in 50 patients with first anterior AMI (165) . Afterward, ANP cardioprotective effects were confirmed in AMI patients by a large multi-center randomized trial (J-WIND-Japan-Working Groups of Acute Myocardial Infarction for the Reduction of Necrotic Damage) (166) . Patients treated by human ANP had a reduced IS (-14.7%) assessed by a CK release, an increased LVEF (5.1%), a reduced IR injury (25.9%), and more importantly, decreased risks of cardiac death or HF compared to the control group (103, 166, 167) . In Japan and the US, Carperitide (28-mer synthetic ANP) or Nesiritide (23-mer synthetic BNP) have been approved as a treatment for acutely decompensated HF. However, adverse events were observed such as relevant hypotension (102) (103) (104) or increased mortality (168) and worsened renal function for Nesiritide (105, 106) . Urodilatin Urodilatin an ANP homolog was used as a pharmacological postconditioning in MIRI models. For example, the cyclic 31mer peptide showed an increased LV pressure in a rat ex vivo IR model when applied during the first 15 min of reperfusion and, furthermore, a reduced IS in a pig in vivo MIRI model after an intravenous administration during the first 25 min of reperfusion (72) . C-type natriuretic peptide (CNP) is a 22-mer peptide, structurally related to but genetically distinct from ANP and BNP. Isolated rat hearts subjected to MIRI revealed smaller IS and a reduced coronary perfusion pressure when treated with CNP during the first 30 min of reperfusion (30 nmol/L) (77) . Lebetin 2 (L2), a 38-mer peptide snake venom-derived NP isolated from Macrovipera lebetina, has the advantage to be more stable compared to human NPs. L2 perfused to rat hearts ex vivo reduced IS similarly to BNP (73) . Interestingly, the same authors showed some years later that L2 has strong and prolonged cardioprotective effects in post-MI (mouse and rat IR models) mainly due to modulation of the inflammatory response as evidenced by enhanced M2-like macrophage detection (76) . Vasonatrin peptide (VNP) is an artificial 22-mer chimeric peptide issued from ANP and CNP showing more potent diuretic, natriuretic, and vasorelaxant properties compared with other NPs (169) . This peptide was able to attenuate MIRI in diabetic rats (administrated 10 min before R) as demonstrated by reduced LV systolic and end-diastolic pressure as well as decreased Caspase-3 activity and plasma CK/lactate dehydrogenase (LDH) quantities (78) . Cardiovascular diseases including AMI ranks first in worldwide mortality and according to WHO, they will stay at this rank until 2030. Currently, despite promising results in animal models, there is no pharmacological treatment, which could be administrated in adjunct to reperfusion therapy to inhibit its adverse effects known as reperfusion injury. Differences between preclinical animal MI models and the clinical scenario in patients, including age, comorbidities, and cotreatments could be an explanation (170, 171) . Other reasons could be related to the limited comprehension of the underlying pathophysiology and the absence of specific biomarkers to clearly identify MIRI. Finally, the therapeutic time-window for the application of pharmacological therapies plays a critical role to provide a successful treatment of reperfusion injury. The burst of cell death induced by reperfusion after prolonged ischemia can only be prevented if the administration of cardioprotectants occurs at the onset of reperfusion and preferably before reopening of the culprit coronary artery (26, 172, 173) . However, even if the time-window of drug administration should be before reperfusion, further investigations are needed to define how long the protective therapy must be applied to fully prevent MIRI. Since MIRI is a complex interplay of different pathways, a strategy involving multiple targets should be considered in the development of pharmacological drugs. Some of the pathways currently being targeted are the different apoptotic pathways, microvasculature circulation, inflammation, platelets, mitochondrial dynamics, and RISK/SAFE pathways leading to cell survival and improved cardiac function (174) . After disappointing results in clinical assays (2014-2016), academic research has forwarded the development of novel therapeutic molecules such as highlighted by more than 1,000 PubMed publications in 2021 (searching keywords: "myocardial ischemia-reperfusion, " "therapy, " "2021"). To succeed in cardioprotection, other aspects of reperfusion injury besides infarct size should be considered in particular microvascular injury since heart function is ensured by both cardiomyocytes and vascular cells (cell ratio 50:50) (174) and early ventricular arrhythmias with a lower contribution. Additionally, considering the development of new therapeutic peptides (or other pharmacological drugs), special attention should be devoted to the improvement of targeting the ischemic zone (or subcellular localization) within the infarcted heart to maximize local drug concentration and reduce side effects. Recently, Zhang and co-workers showed higher mitochondrial integrity, lower apoptosis of cardiomyocytes, and reduced myocardial IS by encapsulating CsA in PEGylated nanoparticles with mitochondria-targeting [CsA@PLGA-PEG-SS31] (127) . Another example is the cyclic heart homing sequence [CSTSMLKAC] grafted on porous silicon nanoparticles revealing an improved accumulation within the heart (up to three-fold) (175) . Taking together, future development of pharmacological drugs to treat AMI patients should be characterized by a drug cocktail or a pleiotropic drug acting specifically on (i) different pathways or (ii) different cell types, or by (iii) an improved tissue or subcellular targeting. The combination of these strategies should provide advantages for future clinical outcomes. PB and SB-L contributed to conception and design of the manuscript. CFR, KK, and PB performed the selection of the therapeutic peptides. PB wrote the first draft of the manuscript. CFR, KK, EJ, JN, SB-L, and PB wrote sections of the manuscript. EJ performed the graphical design of the figures. All authors contributed to manuscript revision, read, and approved the submitted version. Global burden of cardiovascular diseases and risk factors, 1990-2019: update from the GBD 2019 study Diabetes and cardiovascular disease: epidemiology, biological mechanisms, treatment recommendations and future research Global burden of acute myocardial injury associated with COVID-19: a systematic review, meta-analysis, and meta-regression ESC scientific document group. fourth universal definition of myocardial infarction 2018 Cardiology on the cutting edge: updates from the European Society of Cardiology (ESC) Congress 2020 ESC guidelines 2020: acute coronary syndrome without persistent ST-segment elevation: what is new? Acute Myocardial Infarction Mitochondrial and mitochondrial-independent pathways of myocardial cell death during ischaemia and reperfusion injury Factors involved in salvaging ischemic myocardium: effect of reperfusion of arterial blood Ischemia-reperfusion injury: processes in pathogenetic networks: a review Genetic lineage tracing of nonmyocyte population by dual recombinases Myocardial reperfusion: a double-edged sword? Preconditioning and postconditioning: new strategies for cardioprotection Role of cell death in the progression of heart failure Reperfusion injury in acute myocardial infarction The molecular machinery of regulated cell death Fundamental mechanisms of regulated cell death and implications for heart disease Myocardial apoptosis in heart disease: does the emperor have clothes? Reperfusion injury induces apoptosis in rabbit cardiomyocytes Reperfusion induces myocardial apoptotic cell death Mibefradil, a T-Type and L-Type calcium channel blocker, limits infarct size through a glibenclamide-sensitive mechanism Caspase inhibition reduces myocyte cell death induced by myocardial ischemia and reperfusion in vivo Ischemic preconditioning decreases apoptosis in rat hearts in vivo Inhibition of myocardial injury by ischemic postconditioning during reperfusion: comparison with ischemic preconditioning Hypoxic postconditioning enhances the survival and inhibits apoptosis of cardiomyocytes following reoxygenation: role of peroxynitrite formation A novel therapeutic peptide targeting myocardial reperfusion injury Anti-apoptotic peptide for long term cardioprotection in a mouse model of myocardial ischemia-reperfusion injury Mitochondrial permeability transition in cardiac ischemia-reperfusion: whether cyclophilin D is a viable target for cardioprotection? Necroptotic cell death in failing heart: relevance and proposed mechanisms Evidence of necroptosis in hearts subjected to various forms of ischemic insults Molecular mechanisms of cell death: recommendations of the nomenclature committee on cell death Guidelines for evaluating myocardial cell death Cardiac autophagy is a maladaptive response to hemodynamic stress Autophagy is an adaptive response in desmin-related cardiomyopathy Autophagy during cardiac stress: joys and frustrations of autophagy Autosis: a new target to prevent cell death Upregulation of rubicon promotes autosis during myocardial ischemia/reperfusion injury Pathogenesis of myocardial ischemia-reperfusion injury and rationale for therapy Inflammation following acute myocardial infarction: multiple players, dynamic roles, and novel therapeutic opportunities New insights in research about acute ischemic myocardial injury and inflammation. anti-Inflamm Anti C-Reactive Protein (CRP) After Revascularized STEMI: Is CRP a Prognostic Factor? Colchicine and myocardial infarction: a review A comprehensive review on current advances in peptide drug development and design Peptide chemistry toolbox-transforming natural peptides into peptide therapeutics Global Peptide Therapeutics Market Outlook (2019 to 2027)-Featuring Sanofi, Pfizer & Amgen Among Others. Available online at: https:// www.Prnewswire.com/News-Releases/Global-Peptide-Therapeutics-Market-Outlook-2019-to-2027---Featuring-Sanofi-Pfizer--Amgen-Among-Others-301114277.Html Protective roles of bioactive peptides during ischemia-reperfusion injury: from bench to bedside Differential contribution of necrosis and apoptosis in myocardial ischemia-reperfusion injury Bid is cleaved by calpain to an active fragment in vitro and during myocardial ischemia/reperfusion Ischemic preconditioning attenuates ischemia/reperfusion-induced activation of caspases and subsequent cleavage of poly(ADP-Ribose) polymerase in rat hearts in vivo Myocardial expression of a dominant-negative form of daxx decreases infarct size and attenuates apoptosis in an in vivo mouse model of ischemia/reperfusion injury The Influence of B-Cell Lymphoma 2 Protein, an antiapoptotic regulator of mitochondrial permeability transition, on isoflurane-induced and ischemic postconditioning in rabbits Preconditioning and postconditioning Hyperglycaemia blocks sevoflurane-induced postconditioning in the rat heart in vivo: cardioprotection can be restored by blocking the mitochondrial permeability transition pore Cyclosporine A at reperfusion reduces infarct size in pigs Post-conditioning with cyclosporine a fails to reduce the infarct size in an in vivo porcine model Cyclosporine does not reduce myocardial infarct size in a porcine ischemia-reperfusion model Cyclosporine A, 2.5 mg/kg, does not reduce myocardial infarct size in a porcine model of ischemia and reperfusion Cyclosporine A reduces microvascular obstruction and preserves left ventricular function deterioration following myocardial ischemia and reperfusion A highly potent peptide analgesic that protects against ischemia-reperfusion-induced myocardial stunning Reduction of ischemia/reperfusion injury with bendavia, a mitochondria-targeting cytoprotective peptide The cardiolipin-binding peptide elamipretide mitigates fragmentation of cristae networks following cardiac ischemia reperfusion in rats High-dose humanin analogue applied during ischemia exerts cardioprotection against ischemia/reperfusion injury by reducing mitochondrial dysfunction Efficacy of a novel mitochondrial-derived peptide in a porcine model of myocardial ischemia/reperfusion injury Systemic delivery of BH4 anti-apoptotic peptide using cpps prevents cardiac ischemia-reperfusion injuries in vivo Transient receptor potential vanilloid 1 regulates mitochondrial membrane potential and myocardial reperfusion injury Decreased myocardial injury and improved contractility after administration of a peptide derived against the alpha-interacting domain of the L-Type calcium channel US20130288979. Inhibitors of Apoptosis and Uses Thereof. Available onlne at Atrial natriuretic peptide protects against ischemia-reperfusion injury in the isolated rat heart Alphahuman atrial natriuretic peptide, carperitide, reduces infarct size but not arrhythmias after coronary occlusion/reperfusion in dogs Carperitide induces coronary vasodilation and limits infarct size in canine ischemic hearts: role of NO Intravenous administration of the natriuretic peptide urodilatin at low doses during coronary reperfusion limits infarct size in anesthetized pigs Lebetin 2, a snake venom-derived natriuretic peptide, attenuates acute myocardial ischemic injury through the modulation of mitochondrial permeability transition pore at the time of reperfusion Anti-inflammatory effect of B-type natriuretic peptide postconditioning during myocardial ischemiareperfusion: involvement of PI3K/Akt signaling pathway Recombinant human brain natriuretic peptide attenuates myocardial ischemia-reperfusion injury by inhibiting CD4+ T Cell proliferation via PI3K/AKT/MTOR pathway activation Lebetin 2, a snake venom-derived b-type natriuretic peptide, provides immediate and prolonged protection against myocardial ischemiareperfusion injury via modulation of post-ischemic inflammatory response Natriuretic peptide receptor-c regulates coronary blood flow and prevents myocardial ischemia/reperfusion injury: novel cardioprotective role for endothelium-derived C-type natriuretic peptide Vasonatrin peptide attenuates myocardial ischemia-reperfusion injury in diabetic rats and underlying mechanisms Annexin 1 peptides protect against experimental myocardial ischemiareperfusion: analysis of their mechanism of action Cardioprotective actions of the Annexin-a1 N-terminal peptide Annexin 1 mediates the rapid anti-inflammatory effects of neutrophil-derived microparticles Characterizing the antiinflammatory and tissue protective actions of a novel annexin A1 peptide A novel peptide agonist of formyl-peptide receptor-like 1 (ALX) displays antiinflammatory and cardioprotective effects Selectin-targeting glycosaminoglycan-peptide conjugate limits neutrophil mediated cardiac reperfusion injury Protective effects of ghrelin on ischemia/reperfusion injury in the isolated rat heart Ghrelin protects the heart against ischemia/reperfusion injury via inhibition of TLR4/NLRP3 inflammasome pathway Obestatin plays beneficial role in cardiomyocyte injury induced by ischemia-reperfusion in vivo and in vitro Obestatin regulates cardiovascular function and promotes cardioprotection through the nitric oxide pathway Nesfatin-1 attenuates injury in a rat model of myocardial infarction by targeting autophagy, inflammation, and apoptosis Necroptosis and RhoA/ROCK pathways: molecular targets of Nesfatin-1 in cardioprotection against myocardial ischemia/reperfusion injury in a rat model Nesfatin-1 as a novel cardiac peptide: identification, functional characterization, and protection against ischemia/reperfusion injury Helix B surface peptide protects against acute myocardial ischemia-reperfusion injury via the risk and safe pathways in a mouse model Protective Effects of GLP-1 analogues exendin-4 and GLP-1(9-36) amide against ischemia-reperfusion injury in rat heart Glucagon like peptide-1 is protective against myocardial ischemia/reperfusion injury when given either as a preconditioning mimetic or at reperfusion in an isolated rat heart model Apelin-13 administration protects against ischaemia/reperfusion-mediated apoptosis through the Foxo1 pathway in high-fat diet-induced obesity Elabela alleviates myocardial ischemia reperfusioninduced apoptosis, fibrosis and mitochondrial dysfunction through Pi3k/akt signaling EMBRACE STEMI study: a phase 2a trial to evaluate the safety, tolerability, and efficacy of intravenous MTP-131 on reperfusion injury in patients undergoing primary percutaneous coronary intervention Effect of cyclosporine on reperfusion injury in acute myocardial infarction Cyclosporine before PCI in patients with acute myocardial infarction Cyclosporine a in reperfused myocardial infarction: the multicenter, controlled, open-label CYCLE trial Effect of cyclosporine in non-shockable out-of-hospital cardiac arrest: the cyrus randomized clinical trial Multicenter prospective investigation on efficacy and safety of carperitide for acute heart failure in the 'real world' of therapy Human atrial natriuretic peptide and nicorandil as adjuncts to reperfusion treatment for acute myocardial infarction (J-WIND): two randomised trials Acute heart failure volume control multicenter randomized (AVCMA) trial: comparison of tolvaptan and carperitide Short-term risk of death after treatment with nesiritide for decompensated heart failure: a pooled analysis of randomized controlled trials Aaronson Keith D. Risk of worsening renal function with nesiritide in patients with acutely decompensated heart failure Exenatide reduces final infarct size in patients with st-segment-elevation myocardial infarction and short-duration of ischemia Cardioprotective effects of exenatide in patients with st-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention: results of exenatide myocardial protection in revascularization study No benefit of additional treatment with exenatide in patients with an acute myocardial infarction Effect of combination therapy with remote ischemic conditioning and exenatide on the myocardial infarct size: a two-by-two factorial randomized trial (COMBAT-MI) Mitochondrial outer membrane permeabilization during apoptosis: the innocent bystander scenario Bid, a Bcl2 interacting protein, mediates cytochrome c release from mitochondria in response to activation of cell surface death receptors The permeability transition pore complex: another view translational issues for mitoprotective agents as adjunct to reperfusion therapy in patients with ST-segment elevation myocardial infarction Mitochondrial non-specific pores remain closed during cardiac ischaemia, but open upon reperfusion What makes the mitochondria a killer? can we condition them to be less destructive? Mechanistic role of MPTP in ischemia-reperfusion injury Role of mitochondrial calcium and the permeability transition pore in regulating cell death Action of cyclosporine on mitochondrial calcium fluxes Inhibition by cyclosporin A of a Ca2+-dependent pore in heart mitochondria activated by inorganic phosphate and oxidative stress Cyclosporin a binding to mitochondrial cyclophilin inhibits the permeability transition pore and protects hearts from ischaemia/reperfusion injury Postconditioning inhibits mitochondrial permeability transition Inhibition of mitochondrial permeability transition improves functional recovery and reduces mortality following acute myocardial infarction in mice Bioequivalence and tolerability assessment of a novel intravenous ciclosporin lipid emulsion compared to branded ciclosporin in cremophor R EL Nanoliposome containing cyclosporine a reduced neuroinflammation responses and improved neurological activities in cerebral ischemia/reperfusion in rat Mitochondria-targeted cyclosporin a delivery system to treat myocardial ischemia reperfusion injury of rats New nanoparticle formulation for cyclosporin a: in vitro assessment Nanoparticle-mediated simultaneous targeting of mitochondrial injury and inflammation attenuates myocardial ischemia-reperfusion injury Temporal dynamics of immune response following prolonged myocardial ischemia/reperfusion with and without cyclosporine A Cell-permeable, mitochondrial-targeted, peptide antioxidants Humanin: a mitochondrial-derived peptide in the treatment of apoptosisrelated diseases VDAC regulation by the bcl-2 family of proteins Calpain and mitochondria in ischemia/reperfusion injury A Truncated HIV-1 tat protein basic domain rapidly translocates through the plasma membrane and accumulates in the cell nucleus Evidence for regulation of mitochondrial function by the L-Type Ca2+ channel in ventricular myocytes Involvement of CD95/Apo1/Fas in cell death after myocardial ischemia Fas pathway is a critical mediator of cardiac myocyte death and mi during ischemiareperfusion in vivo differential gene expression following early renal ischemia/reperfusion Necrostatin-1 protects hippocampal neurons against ischemia/reperfusion injury via the RIP3/DAXX signaling pathway in rats Subcellular localization of Daxx determines its opposing functions in ischemic cell death therapeutic potential of annexin a1 in ischemia reperfusion injury Anti-inflammatory lipocortin-derived peptides Regulation of inflammation and oxidative stress by formyl peptide receptors in cardiovascular disease progression Selectin-targeting peptide-glycosaminoglycan conjugates modulate neutrophil-endothelial interactions Drug insight: the functions of ghrelin and its potential as a multitherapeutic hormone protective effects of ghrelin against oxidative stress, inducible nitric oxide synthase and inflammation in a mouse model of myocardial ischemia/reperfusion injury via the HMGB1 and TLR4/NF-?B pathway Obestatin affords cardioprotection to the ischemic-reperfused isolated rat heart and inhibits apoptosis in cultures of similarly stressed cardiomyocytes Erythropoietin in cardiac disease: effective or harmful? Non-erythropoietic, tissue-protective peptides derived from the tertiary structure of erythropoietin A small non-erythropoietic Helix B surface peptide based upon erythropoietin structure is cardioprotective against ischemic myocardial damage Helix B surface peptide attenuates diabetic cardiomyopathy via AMPKdependent autophagy Helix B surface peptide protects cardiomyocytes from hypoxia/reoxygenation-induced autophagy through the PI3K/Akt pathway Glucagon-like peptide 1 can directly protect the heart against ischemia/reperfusion injury Glucagon-like peptide (glp)-1(9-36)amide-mediated cytoprotection is blocked by exendin(9-39) yet does not require the known GLP-1 receptor Effects of liraglutide on reperfusion injury in patients with st-segmentelevation myocardial infarction Effects of liraglutide on left ventricular function in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention Glucagon-like peptide-1: a promising agent for cardioprotection during myocardial ischemia Isolation and characterization of a novel endogenous peptide ligand for the human APJ receptor The role of apelin in cardiovascular function and heart failure Apelin-13 and apelin-36 exhibit direct cardioprotective activity against ischemia-reperfusion injury Apelin increases cardiac contractility via protein kinase cε-and extracellular signal-regulated kinase-dependent mechanisms Metabolic actions of natriuretic peptides and therapeutic potential in the metabolic syndrome Administration of atrial natriuretic peptide attenuates reperfusion phenomena and preserves left ventricular regional wall motion after direct coronary angioplasty for acute myocardial infarction Effects of intravenous atrial natriuretic peptide on cardiac sympathetic nerve activity and left ventricular remodeling in patients with first anterior acute myocardial infarction J-WIND investigators. rationale and design of a large-scale trial using atrial natriuretic peptide (ANP) as an adjunct to percutaneous coronary intervention for ST-segment elevation acute myocardial infarction: Japanworking groups of acute myocardial infarction for the reduction of necrotic damage by ANP (J-WIND-ANP) Rationale and design of a large-scale trial using nicorandil as an adjunct to percutaneous coronary intervention for stsegment elevation acute myocardial infarction: japan-working groups of acute myocardial infarction for the reduction of necrotic damage by a K-ATP channel opener (J-WIND-KATP) Carperitide is associated with increased in-hospital mortality in acute heart failure: a propensity score-matched analysis Vasonatrin peptide: a unique synthetic natriuretic and vasorelaxing peptide The pathophysiology of acute myocardial infarction and strategies of protection beyond reperfusion: a continual challenge Interaction of risk factors, comorbidities, and comedications with ischemia/reperfusion injury and cardioprotection by preconditioning, postconditioning, and remote conditioning Delayed postconditioning in the mouse heart in vivo Pharmacological approaches to reperfusion therapy Multitarget Strategies to Reduce Myocardial ischemia/reperfusion injury: JACC review topic of the week In Vitro and in vivo assessment of hearthoming porous silicon nanoparticles The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.