SGLT2 inhibitor ameliorates endothelial dysfunction associated with the common<i>ALDH2</i>alcohol flushing variant

Abstract

The common aldehyde dehydrogenase 2 (<i>ALDH2</i>) alcohol flushing variant known as <i>ALDH2*2</i> affects ∼8% of the world's population. Even in heterozygous carriers, this missense variant leads to a severe loss of ALDH2 enzymatic activity and has been linked to an increased risk of coronary artery disease (CAD). Endothelial cell (EC) dysfunction plays a determining role in all stages of CAD pathogenesis, including early-onset CAD. However, the contribution of <i>ALDH2*2</i> to EC dysfunction and its relation to CAD are not fully understood. In a large genome-wide association study (GWAS) from Biobank Japan, <i>ALDH2*2</i> was found to be one of the strongest single-nucleotide polymorphisms associated with CAD. Clinical assessment of endothelial function showed that human participants carrying <i>ALDH2*2</i> exhibited impaired vasodilation after light alcohol drinking. Using human induced pluripotent stem cell-derived ECs (iPSC-ECs) and CRISPR-Cas9-corrected <i>ALDH2*2</i> iPSC-ECs, we modeled <i>ALDH2*2</i>-induced EC dysfunction in vitro, demonstrating an increase in oxidative stress and inflammatory markers and a decrease in nitric oxide (NO) production and tube formation capacity, which was further exacerbated by ethanol exposure. We subsequently found that sodium-glucose cotransporter 2 inhibitors (SGLT2i) such as empagliflozin mitigated <i>ALDH2*2</i>-associated EC dysfunction. Studies in <i>ALDH2*2</i> knock-in mice further demonstrated that empagliflozin attenuated <i>ALDH2*2</i>-mediated vascular dysfunction in vivo. Mechanistically, empagliflozin inhibited Na⁺/H⁺-exchanger 1 (NHE-1) and activated AKT kinase and endothelial NO synthase (eNOS) pathways to ameliorate <i>ALDH2*2</i>-induced EC dysfunction. Together, our results suggest that <i>ALDH2*2</i> induces EC dysfunction and that SGLT2i may potentially be used as a preventative measure against CAD for <i>ALDH2*2</i> carriers.