Sex differences in myocardial ketone oxidation capacity in cardiometabolic disease with coincident ischemic heart disease

Background: Myocardial infarction (MI) in patients with heart failure with preserved ejection fraction (HFpEF) is associated with worse outcomes than MI in individuals without HFpEF. However, the molecular mechanisms underlying this increased vulnerability remain poorly understood. We investigated sex differences in cardiac ketone body (KB) metabolism in patients with diabetes-associated ischemic heart disease, and in a mouse model of HFpEF complicated by MI (HFpEF-MI). Methods: Cardiac BDH1 and OXCT1 expression was assessed in male and female patients with diabetes, with or without ischemic heart disease. Male and female mice received a high-fat diet and L-NAME for 10 weeks to induce HFpEF, followed by coronary artery ligation to induce MI. Glucose tolerance, cardiac function, survival, cardiac KB oxidative capacity, and circulating KB levels were evaluated. Results: Cardiac BDH1 and OXCT1 abundance was significantly reduced in male patients with diabetes-associated ischemic heart disease but preserved in female patients. In mice, 10 weeks of high-fat diet and L-NAME administration increased fasting blood glucose and impaired glucose tolerance. MI reduced systolic function in control and HFpEF mice of both sexes. Male HFpEF-MI mice exhibited higher mortality than female HFpEF-MI mice. Consistent with our human results, male HFpEF-MI mice showed reduced cardiac ketolytic enzyme expression alongside elevated circulating KB levels, whereas female mice maintained cardiac KB oxidative capacity. Conclusion: Reduced cardiac ketolytic enzyme expression and impaired KB oxidative capacity are associated with greater mortality in male HFpEF-MI mice, whereas female mice exhibit preserved KB oxidative capacity and improved survival. Similar sex differences in ketolytic enzyme expression were observed in patients with diabetes-associated ischemic heart disease. These findings identify cardiac ketone metabolism as a potential therapeutic target warranting further investigation in HFpEF complicated by MI.