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For example, expression of -hydroxybutyrate dehydrogenase 1 (a key enzyme in the ketone oxidation pathway) and ketogenic -hydroxybutyryl-CoA, in association with increased myocardial utilization of -hydroxybutyrate, is increased in the heart failure samples supported the notion that the hypertrophied and failing heart shifts to ketone bodies as an alternate fuel and myocardial ketone oxidation as a key metabolic adaptation in the failing human heart