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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 4  |  Page : 170-178

Exosome biomarkers in cardiovascular diseases and their prospective forensic application in the identification of sudden cardiac death


1 Department of Forensic Medicine, Nanjing Medical University, Nanjing, China
2 Department of Forensic Medicine, Nanjing Medical University, Nanjing, China; Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center for Cardiovascular Disease Translational Medicine, Nanjing Medical University, Nanjing, China

Date of Submission06-Oct-2022
Date of Decision12-Dec-2022
Date of Acceptance12-Dec-2022
Date of Web Publication30-Dec-2022

Correspondence Address:
Dr. Feng Chen
Department of Forensic Medicine, Nanjing Medical University, Nanjing, China; Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center for Cardiovascular Disease Translational Medicine, Nanjing Medical University, Nanjing
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfsm.jfsm_118_22

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  Abstract 


Sudden cardiac death (SCD) is a common cause of death due to the high prevalence and mortality of cardiovascular disease (CVD). Currently, the forensic identification of SCD relies on traditional histomorphological examination, lacking stable biomarkers with high specificity and sensitivity. Previous studies have shown that exosomes (Exos) are ideal vectors and the application of Exos provides novel insight as the diagnostic biomarkers and treatment of CVD, and is hot research filed in biomedicine. This review briefly describes the biology of Exos, including the biogenesis of Exos and the mechanisms of action. The research progresses on Exos multi-omics, i.e., genomics, proteomics and metabolomics, and their roles in the diagnosis of different types of CVD, especially coronary heart disease and cardiomyopathy, are summarized. In addition, the current difficulties of applications of Exos in forensic identification of SCD and the prospective forensic applications in the future are highlighted. The aim of this review is to summarize the current advances of Exos in CVD in a disease-oriented manner, and to provide a reference for future forensic pathological identification of SCD, as well as the early diagnosis of SCD in clinic.

Keywords: Cardiovascular disease, cause of death, exosomes, forensic pathology, sudden cardiac death


How to cite this article:
Wang Y, Wang J, Hu L, Huang S, Cao Y, Yu Y, Chen F. Exosome biomarkers in cardiovascular diseases and their prospective forensic application in the identification of sudden cardiac death. J Forensic Sci Med 2022;8:170-8

How to cite this URL:
Wang Y, Wang J, Hu L, Huang S, Cao Y, Yu Y, Chen F. Exosome biomarkers in cardiovascular diseases and their prospective forensic application in the identification of sudden cardiac death. J Forensic Sci Med [serial online] 2022 [cited 2023 Jan 28];8:170-8. Available from: https://www.jfsmonline.com/text.asp?2022/8/4/170/366415


  Introduction Top


Death within 24 h of the onset of symptoms is defined as sudden death (SD). Sudden cardiac death (SCD) is an unexpected and rapid natural death caused by cardiovascular disease (CVD), characterized by sudden loss of consciousness from cardiac causes, and is the most common form of SD.[1] According to the World Health Organization, approximately 17.7 million people died from CVD in 2015, accounting for 31% of all global deaths.[2] The incidence of SCD in Chinese residents was about 41.84/100,000, and 544,000 people suffered from SCD every year, ranking the first in the world.[1] The most common CVDs with the worst clinical prognosis are Coronary heart disease (CHD)[3] and cardiomyopathy.[4],[5]

As most SCD cases occur rapidly, medical records or eyewitnesses are often absent. Therefore, the symptoms and the onset of death are poorly documented. The identification of SCD is always a problem and one of the research focuses in forensic medicine.

Currently, in forensic medical practice, the identification of CVD in SCD cases mainly relies on traditional histomorphological methods, lacking objective biomarkers with high specificity, sensitivity, and stability. Previous studies have shown that exosomes (Exos) have a stable double-membrane structure, maintaining integrity with high stability. Exos contain a variety of active substances such as RNAs, proteins, lipids, and metabolites.[6] Alterations of these components released by specific cell types reflect the disease states of the body, allowing Exos to be taken as potential vectors of diagnosing biomarkers of SCD in forensic identification. In recent years, studies on Exos in diseases are mainly focused on cancers, diabetes, liver and kidney diseases, and CVDs.[7],[8],[9],[10],[11],[12]

This review summarizes the research progress of Exos in CVD, providing an overview of Exos biology, and how genomic, proteomic and metabolomic studies of Exos have been applied to clinical diagnosis of CHD and cardiomyopathy. For example, miR-208a[13] and miR-21[14] of plasma Exos are emerging genomic biomarkers for the diagnosis of CHD and cardiomyopathy; heat shock protein (HSP) 20, HSP60, and others[15],[16],[17] are proteomic markers for the diagnosis of these two diseases; phosphatidylcholine[18] and acylcarnitine[19] are metabolomic biomarkers for the diagnosis of the two diseases. In this paper, we summarize these novel biomarkers and prospect the diagnostic value of Exos in clinic and forensic medicine, aiming to provide a reference for forensic identification and clinical risk prediction of SCD.


  The Biology of Exosomes Top


Extracellular vesicles (EVs) refer to any microscopic vesicles released by cells, which are spherical with lipid bilayer membrane structures. EVs contain bioactive substances such as proteins, DNAs, RNAs, long noncoding RNAs and lipids,[20] and can be secreted by almost all cell types, including immune cells, mesenchymal stem cells and blood cells. EVs are widely distributed in blood, urine and other body fluids, exerting its biological functions. According to their biological characteristics, EVs can be divided into Exos, microvesicles, and apoptotic bodies, as shown in [Table 1].
Table 1: Classification of extracellular vesicles[21]

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Exosome biogenesis

The transport system of Exos is multifunctional in human body, which is involved in regulating all aspects of cell biology through the transfer of information between cells. According to the ExoCarta Exos database,[27] 9,769 proteins, 3,408 mRNAs, 2,838 miRNAs and 1,116 lipids have been found in 286 types of Exos. Biogenesis of Exos requires endocytosis, double invagination of plasma membrane and formation of multivesicular bodies (MVBs).[19] Under the stimulation of external conditions, the plasma membrane invaginates for the first time. Extracellular active substances such as nucleic acids, proteins, lipids and metabolites enter the cell together with plasma membrane surface proteins through endocytosis to form endocytosis vesicles. Early-sorting endosomes (ESEs) are formed by the fusion of multiple endosomal vesicles. Subsequently, ESEs endocytosis mitochondria, endoplasmic reticulum, Golgi bodies, and nucleic acids form late-sorting endosomes (LSEs). After that, LSEs develop a second internment under the action of endosomal sorting complexes required for transport (ESCRT), and then, multiple inter-luminal vesicles (ILVs) of different sizes are developed. For this reason, LSEs with ILVs are called MVBs. A few MVBs are eventually degraded by autophagosomes or lysosomes, while most of them fuse with the plasma membrane to release ILVs and eventually Exos, as is shown in [Figure 1].[6]
Figure 1: Biogenesis of exosomes

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The formation of Exos requires the synergistic action of multiple protein networks in cells. Among them, Rat sarcoma (RAS)-related protein Rab GTPase controls endosomal transport. The ESCRT protein complex regulates ILV formation. Different lipid-modifying enzymes, such as sphingomyelinase, can produce accelerated vesicles to produce ceramides.[28] In addition, sytenin-1, TSG101, apoptosis linked gene 2-interacting protein X (ALIX), CD9, CD63, CD81, LAMP1, HSP, phospholipid, tetraspanins, and soluble N-ethylmaleimide-sensitive factor attached protein receptor (SNARE) are all involved in the biogenesis of Exos. However, their precise rate-limiting role and function in Exos biogenesis need further research.[20],[29] Among them, ALIX, CD9, CD63, CD81, LAMP1, TSG101, and SNARE are specific markers of Exos. Moreover, Exos carry specific information of different cell sources, indicating different physiological and pathological states of the body.

Mechanism of action of exosomes

Exos have a structure called lipid raft, which is cholesterol-rich membrane microdomain. The lipid bilayer of Exos is mainly constituted of plasma membrane lipids, including phosphatidylcholine, ganglioside, sphingomyelin, and phosphatidylethanolamine.[30] Exos are known to use three mechanisms for cellular communication. The first is internalization. Exos are internalized by target cells through clathrin-dependent endocytosis, macropinocytosis, and lipid raft-dependent endocytosis, transferring the information of mother cell origin to target cells and expressing in target cells, thereby affecting the phenotype and function of target cells.[20] The second is direct fusion,[31] by which the Exo membrane is fused with the target cell membrane, so that the Exo contents enter the cytoplasm of the target cell to realize information transmission. The third is receptor-ligand interaction.[32] Exos interact with receptor ligands on the surface of recipient cells and initiate intracellular signaling pathways, transferring information to receptors without entering cells. Exos, surface receptors and adhesion molecules of target cells, such as quad transmembrane proteins, integrins, proteoglycan, and lectins, are involved in mediating the selection of target cells.[28],[33],[34] In addition, the interaction among SNAREs promotes the fusion of MVB with target cell membrane.[28],[35],[36] The mechanism of Exos uptake by target cells may vary depending on the composition of Exos and some specific structures on the target cell membrane.[28]

Purification of exosomes

The overspeed centrifugation (ultracentrifugation) method is the most widely used Exos separation technology, which is known as the “gold standard” of Exos extraction and separation.[37] Besides, there are other methods for exosome isolation, including density gradient centrifugation,[38] polymer precipitation method,[39] and ultrafiltration and size-exclusion chromatography.[40] A comparison of the commonly used methods for Exos isolation and purification is shown in [Table 2].
Table 2: Comparison of commonly used methods for exosomes isolation and purification

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  Exosome Biomarkers in Cardiovascular Diseases Top
xs

Overview of cardiovascular diseases

CVD is among the most harmful diseases with the highest incidence rate of SD in adults. According to the China Cardiovascular Health and Disease Report 2020, the prevalence of CVD in China has been on the rise.[2] Currently, there are about 330 million patients with CVD, including 11.39 million with CHD, 8.9 million with heart failure and 2 million with congenital heart disease. In 2018, CVD remained the leading cause of death, accounting for 46.66% and 43.81% of the deaths in rural and urban areas, respectively.

Currently, the diagnostic criteria used in clinical practice have shortcomings such as laggard and poor specificity. Therefore, in-depth study of the molecular pathophysiology of CVD and search for new biomarkers are crucial for the early prevention and diagnosis of CVD. Evidences have proven that Exos have great potential as vectors of biomarkers in the diagnosis of CVD,[41] which are expected to improve the shortcomings of conventional clinical diagnosis of CVD, thereby detecting disease risk more sensitively and earlier, building more comprehensive risk prediction models, and reducing the incidence of CVD.

Coronary heart disease

Overview of coronary heart disease

CHD is caused by coronary atherosclerotic plaque and its complications, leading to coronary vascular lumen stenosis, spasm and even obstruction, resulting in myocardial insufficiency of blood supply, myocardial ischemia and hypoxia. Therefore, CHD is also known as ischemic heart disease, mainly manifested as angina pectoris and myocardial infarction (MI), myocardial fibrosis and even SD CHD is divided into chronic coronary syndrome and acute coronary syndrome (ACS). The former is also known as stable coronary artery disease, including stable angina pectoris, ischemic cardiomyopathy (ICM) and ACS after treatment. The latter includes acute MI (AMI) and unstable angina (UA).

Common methods used in the clinical evaluation of CHD are ancillary tests. Coronary angiography is a common auxiliary examination, which is the “gold standard” for the diagnosis of CHD. Common clinical biomarkers include high-density lipoprotein (HDL), low density lipoprotein (LDL), troponin family and creatine kinases, etc., High levels of LDL suggest a high risk of CHD,[42] while decreased HDL is strongly negatively correlated with CHD.[43] Troponin level is positively correlated with infarct size and peaks at 12 h after MI, but its specificity is low.

In conclusion, the current diagnostic system is not comprehensive, and there are still a significant number of patients at high risk levels who are under-diagnosed.

Exosome biomarkers in the diagnosis of coronary heart disease

Cardiogenic Exos are EVs secreted by cardiac cells including cardiomyocytes, endothelial cells, vascular smooth muscle cells, cardiac fibroblasts, inflammatory cells and stem cells, which maintain cardiac homeostasis and constitute a signaling network for cardiac cells to work together.

MicroRNAs

ACS is the manifestations of acute attack of CHD, which often lead to SD Therefore, rapid diagnosis and early intervention of CHD are particularly important. Studies have found that plasma miRNAs are upregulated in AMI patients. For example, miR-208a specifically peaks 4 h after the onset of chest pain symptoms, 8 h earlier than troponin change.[44] MiR-1 and miR-133a are also found to be specifically upregulated in the plasma of ACS patients.[45] Studies have shown that elevated plasma levels of miR-208b and miR-499-5p may indicate higher mortality or an increased risk of heart failure. MiR-192, miR-194 and miR-34a are p53-reactive miRNAs, and their up-regulations in plasma of AMI patients also suggest a high risk of heart failure. In addition, other miRNAs were found to be differentially expressed in CHD, and the mechanisms have gradually been elucidated, as shown in [Table 3].
Table 3: Differential exosomal miRNAs in cardiovascular disease and the underlying mechanisms

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Proteomics

At present, based on protein identification methods such as liquid chromatography coupled mass spectrometry (MS), the differences of Exos proteins in physiological or pathological states of organisms can be observed.[59]

Peroxisome proliferator-activated receptor-γ, a nuclear receptor that regulates adipocyte differentiation and proliferation as well as immune and inflammatory cell functions, has been identified to be a component of plasma Exos, which may serve as a potential new pathway for paracrine transfer of nuclear receptors.[60]

Cardiomyocyte HSP20 and HSP60 are enriched in Exos, which regulate cardiomyocyte growth and survival under stress. HSP60 activates the innate immune system via Toll-like receptor 4 and induces apoptosis in cardiomyocytes.[15],[16],[17] Tumour necrosis factor-alpha (TNF-α) overexpression is harmful to cardiomyocytes in AMI. In the early stages of myocardial ischemia, hypoxia-inducible factors-1α initiates the expression of TNF-α, which is released mainly from macrophages. The initiating factor and precise molecular mechanism of TNF-α release from cardiomyocytes is not known.[61]

Metabolomics

Metabolomics mainly studies small molecular metabolites with molecular weight below 1,000, including lipids, sugars, amino acids, nucleotides, etc., At present, nuclear magnetic resonance and chromatography- MS are commonly used to analyze metabolomics profile. The former can be used for real-time monitoring without destroying samples, but the sensitivity is low, while the latter has high sensitivity, but requires complex sample pretreatment and is difficult to determine unknown metabolites.[62]

Metabolomics study can distinguish metabolic characteristics between different diseases, and also help to distinguish CHD patients from healthy individuals. Some studies have found metabolites that differ between ST-segment elevation MI (STEMI) and the control group, including phosphatidylcholine, lysophosphatidylcholine, sphingomyelin and biogenic amines.[18] These metabolites are expected to be new biomarkers and drug targets for STEMI. In addition, metabolomics analysis of Exos in CHD patients is beneficial to deepen our understanding of the disease. Studies have shown that serum leucine is significantly upregulated in patients with non-STEMI compared to healthy individuals, while C5DC, C16:1-OH, C26/C20 and C18:1 are significantly increased in patients with STEMI. Leukotriene B4 is significantly upregulated in patients with UA compared to healthy individuals, indicating enhanced foam cell conversion in patients. Glycocholic acids, bile acids and thioglycolic acids are up-regulated in UA patients compared to healthy individuals, indicating liver dysfunction. In addition, serum ceramide is upregulated in UA patients, indicating increased ceramide kinase activity and accelerating apoptosis of vascular smooth muscle cells.[63]

Cardiomyopathy

Overview of cardiomyopathy

The prevalence of cardiomyopathy in developed countries is approximately 0.7–7.5/100,000 people. In China, cardiomyopathies account for approximately 1.5%–2.5% of patients with heart diseases. Cardiomyopathies are defined as a heterogeneous group of myocardial diseases associated with mechanical and/or electrical dysfunction, usually (but not always) manifesting as inappropriate ventricular hypertrophy or dilation, which can be caused by a variety of causes and are often hereditary. Cardiomyopathies often lead to cardiovascular death or progressive disability associated with heart failure. Cardiomyopathies can be classified into primary cardiomyopathy and secondary cardiomyopathy.[5] The primary cardiomyopathy includes dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy, restrictive cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, ion channel disease and other diseases related to genetic factors. Secondary cardiomyopathy is also known as specific cardiomyopathy, and the common ones include diabetic cardiomyopathy, septic cardiomyopathy, perinatal cardiomyopathy and Keshan disease. Cardiomyopathy, which can eventually lead to arrhythmias and heart failure, is the second most common cause of SCD after CHD.[64]

Routine clinical markers of cardiomyopathy

Electrocardiogram, echocardiography,[65],[66] cardiac magnetic resonance[67],[68] and cardiac radionuclide examination are commonly used to diagnose cardiomyopathy. Traditional clinical imaging often fails to be both exceptional and convenient. Most of the examinations are only applied after the patient has cardiac dysfunction, and are not prospective.[69] Due to the high heterogeneity of clinical manifestations in patients with cardiomyopathy, most patients do not show obvious symptoms before diagnosis, until chest pain or dyspnea, even syncope and SD occurs. Without applicable biomarkers to assist early diagnosis, the treatments of cardiomyopathy are often limited to managing arrhythmias and heart failure, which are difficult to improve the quality of life of patients, and cannot effectively reduce the mortality of cardiomyopathy.[70]

Exosome biomarkers in diagnosis of cardiomyopathy

microRNAs

Studies have found that Exos derived from cardiac fibroblasts contain miR-21, which induces myocardial hypertrophy.[14] In addition, in DCM patients, the expression of miR-126 derived from cardiomyocytes is down-regulated and the expression of miR-320 is up-regulated, which inhibits endothelial cell proliferation and angiogenesis.[71] The level of Exos miR-20b-5p in peripheral blood of DCM patients increases, which inhibits the expression of human protein kinase (p-Akt) B interacting protein and glycogen synthase, and impairs insulin mediated glucose metabolism.[72] In septic cardiomyopathy, plasma Exos miR-223 is down-regulated, leading to the overexpression of its target protein, which inhibits myocardial function.[73],[74] Other relevant miRNAs are listed in [Table 3].

Proteomics

In DCM, HSP20 reduction may be involved in the occurrence of the disease and accelerate its progression towards heart failure.[75] Exos protective proteins, including phosphorylated AKT, SOD1, and survivin, are distributed in cardiomyocytes to promote myocardial angiogenesis, reduce oxidative stress, and improve cardiac injury.[5] The contents of NADPH oxidase, Nitric oxide (NO) synthase and protein disulfide isomerase in plasma Exos of patients with septic cardiomyopathy are increased, which can promote cardiac production of NO, impair cardiac function and inhibit myocardial contractility.[76] In diabetic patients, downregulation of HSP20 leads to cardiac injury and cardiomyopathy. In contrast, overexpression of HSP20 in diabetic cardiomyocytes significantly increases Exos survivin and phosphorylated p-Akt, which reduces oxidative stress and decreases adverse cardiac remodeling.[77]

Metabolomics

Studies have found that acylcarnitine, succinic acid, malic acid, methylhistidine, aspartic acid, methionine and phenylalanine are potential biomarkers for the diagnosis of DCM.[78] 1-Pyrrolin-2-carboxylate, n-valine, lysophosphatidylinositol (16:0/0:0), phosphatidyl glycerol, hydroxy fatty acid ester and phosphatidyl choline are potential biomarkers for differentiating DCM from ICM. Acylcarnitine, isoleucine, linoleic acid and tryptophan are the main biomarkers for monitoring the therapeutic effect of DCM.[19] Studies of Exos metabolomics in cardiomyopathies contribute to early detection of disease onset and prevention of disease in later life, and suggest potential mechanisms to elucidate pathogenesis.

Other cardiovascular diseases

Exos can also be used as a biomarker for other CVDs such as myocarditis and heart failure. One study found that the pro-glycolytic reprogramming effect of miR-142 in immune myocarditis promoted immunometabolic dysfunction in CD4+ T cells.[79] Retinol binding protein 4 may be a potential specific biomarker for early screening and diagnosis of myocarditis.[80] Differential expression of miR-92b-3p, miR-1306-5p and miR-let-7b-3p in patients with atrial fibrillation compared to patients with normal sinus rhythm.[81]


  Prospective Applications of Exosome Biomarkers in Forensic Identification of Sudden Cardiac Death Top


In forensic practice, most SCD cases do not have eyewitnesses, and even if they do, their descriptions of the scene may not be entirely accurate, making it difficult to directly use the eyewitness testimony as evidence to identify the cause of death. For example, in cases where violent injuries co-exist with CVD, it is possible that an injury witnessed is only a contributing factor of death but can be easily mistaken for the underlying cause of death, leading to a miscarriage of justice for the suspect. However, in some cases, the suspects who have violently caused the death of another person are falsely claimed or even disguise the cause of death of the victim as SCD in order to escape suspicion, which will result in the suspect escaping culpability if the cause of the victim's death cannot be clearly identified. In view of this, it is of great significance to determine the cause of death of SCD in forensic practice, but it is often extremely difficult to restore the truth.

The research of Exos in CVD provides a new idea for forensic identification of SCD. First, current studies of Exos have provided deeper understandings of the pathogenesis of CVD, which may assist to update the theories of the identification of the cause of death. Second, Exos are secreted extracellularly and can function distantly in body fluids such as pericardial fluid[82] and cerebrospinal fluid,[83] in addition to blood plasma. This means that Exos are not dependent on cardiac tissue samples for SCD identification, and are more readily available for forensic examination when identifying SCD, and it also signifies that Exos can be used to great advantage in forensic medicine. As a carrier of biomarkers, Exos can accurately diagnose CVD and have potential applications in forensic practice to clarify the cause of death and restore the truth of the case.

In forensic practice, the idle biomarker for diagnosis of the cause of death should be stable under the postmortem conditions. Most of the reported biomarkers are circulating proteins and metabolites, which are degraded fast and easily after death. Exos, with lipid bilayer membrane structures, are more likely to preserve their contents from decomposition compared with other components in circulation. Contents of Exos, including proteins, metabolites and miRNAs, are highly specific in different diseases, many of which have been identified to be potential biomarkers of cardiac diseases in clinic, and may also be used as postmortem biomarkers in forensic medicine. More researches for validating those known Exos biomarkers and exploring novel postmortem Exos biomarkers are required.

However, because current Exos isolation and purification technologies are expensive and Exos are susceptible to environmental changes, establishing a standardized postmortem Exos purification protocol for forensic identification is in urgent need. In addition, the use of Exos to identify the cause of death is new in forensic practice and has a number of limitations.

On one hand, Exos isolation requires fresh body fluids, expensive equipments and skilled workers. On the other hand, the decay and decomposition of the body often occur in forensic identification. Exos also decline during the process of decomposition, which is not conducive to downstream analysis, leading to the unreliable results. It has been shown that 18s rRNA levels are subjected to a certain pattern of postmortem degradation under the influence of temperature, humidity and insects.[84] In contrast, miRNAs are more stable due to their shorter length. It has been found that high AU and UA dinucleotide sequence content are highly unstable signaling molecules and there is a significant correlation between miRNA decay rate and AU + UA dinucleotide content.[85] In Matt's study, miR-103 was the relatively stable transcript.[86] Therefore, in forensic identification, miRNAs with long decay time can be selected as biomarkers for cause of death identification. As postmortem decay of miRNAs has been studied extensively and reliably enough, a database of postmortem decay of miRNAs can be established to provide a reference for identification. In addition, the current use of Exos to analyze CVD is focused on clinical patients, with fewer studies on cadavers, and the specificity and sensitivity of Exos as postmortem biomarkers require further study. The use of Exos biomarkers as court evidence in routine cause-of-death determinations currently lacks credibility. The author believes that as the understanding of Exos bioregulation deepened and the techniques for detecting and analyzing Exos expression profiles gradually improved, the number of exploratory studies of the use of Exos in forensic pathology will increase rapidly, and the breadth and depth of researches will be extended.


  Conclusion Top


This review updates the research progress of Exos in CVD, describes the occurrence, isolation and mechanisms of actions of Exos, and summarizes current studies of miRNAs, proteomics and metabolomics of Exos in CHD and cardiomyopathy. The Exos biomarkers mentioned here are shown in [Figure 2]. This review provides an outlook of the forensic application of Exos, expecting that Exos can be applied to forensic pathology in the near future, and become an auxiliary tool for forensic identification of SCD, providing more impartial and credible evidence for the court.
Figure 2: The potential Exos biomarkers in the diagnois is SCD covered in this paper. SCD: Sudden cardiac death

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Acknowledgment

This work was supported by the National Natural Science Foundation of China (No. 81922041, No. 82225023, and No. 82121001), the Open Project of State Key Laboratory of Cardiovascular Diseases (SKL2021019), the China Postdoctoral Science Foundation (2021M701758), and the Postdoctoral Research Project of Gusu School of Nanjing Medical University (GSBSHKY202103).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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