Christopher J. Charles

Beneficial Hemodynamic and Renal Effects of Adrenomedullin in an Ovine Model of Heart Failure

BACKGROUND Adrenomedullin is a recently discovered endogenous peptide with hypotensive and natriuretic actions in normal animals. Circulating and ventricular adrenomedullin are elevated in congestive heart failure, suggesting a possible role in the pathophysiology of this disease. No studies have previously examined the effects of adrenomedullin in heart failure. METHODS AND RESULTS Eight sheep with pacing-induced heart failure received human adrenomedullin(1-52) at 10 and 100 ng x kg(-1) x min(-1) I.V. for 90 minutes each. Compared with vehicle control data, adrenomedullin increased plasma cAMP (high dose, P<.05) in association with dose-dependent falls in calculated peripheral resistance (13 mm Hg x L(-1) x min(-1), P<.001), mean arterial pressure (9 mm Hg, P<.001), and left atrial pressure (5 mm Hg, P<.001) and increases in cardiac output (0.5 L/min, P<.001). Adrenomedullin increased urine sodium (threefold, P<.05), creatinine (P<.05) and cAMP excretion (P<.01), creatinine clearance (P<.05), and renal production of cAMP (P<.05), whereas urine output was maintained during infusion and raised after infusion (P<.05). Adrenomedullin reduced plasma aldosterone levels (P<.05), whereas plasma atrial and brain natriuretic peptide concentrations were unchanged during infusion and rose after infusion (P<.01 and P<.05, respectively). Plasma catecholamine, cortisol, renin, calcium, and glucose concentrations were not significantly altered. CONCLUSIONS Adrenomedullin reduced ventricular preload and afterload and improved cardiac output in sheep with congestive heart failure. Despite the clear fall in arterial pressure, adrenomedullin increased creatinine clearance and sodium excretion and maintained urine output. These results imply an important pathophysiological role for adrenomedullin in the regulation of pressure and volume in heart failure and raise the possibility of a new therapeutic approach to this disease.

Beneficial hemodynamic, endocrine, and renal effects of urocortin in experimental heart failure: Comparison with normal sheep

OBJECTIVES The goal of this study was to determine the bioactivity of urocortin (Ucn) in experimental heart failure (HF). BACKGROUND Urocortin may participate in cardiovascular function and pressure/volume homeostasis. Its effects in HF are unknown. METHODS Eight normal sheep and eight sheep with pacing-induced HF received ovine Ucn (10, 50, and 100 mg intravenous boluses at 2-h intervals) in vehicle-controlled studies. RESULTS Urocortin boluses dose-dependently increased plasma Ucn (p < 0.001). Pharmacokinetics were similar in normal and HF sheep with half-lives approximating 1.3 and 19.5 h for the first and second phases, respectively. In HF, cardiac output increased (twofold), while peripheral resistance, left atrial pressure (both 50% falls: p < 0.001), and mean arterial pressure (p < 0.05) fell. In normal sheep, changes in peripheral resistance and atrial pressure were blunted and in arterial pressure were directionally opposite. Urocortin induced persistent, dose-dependent falls (30% to 50%) in plasma vasopressin, renin activity, aldosterone, natriuretic peptides (all p < 0.001), and endothelin-1 (p < 0.05) in HF sheep, while adrenocorticotrophic hormone and cortisol levels rose acutely (both p < 0.001). In comparison, Ucn in normal sheep resulted in a similar rise in cortisol and fall in aldosterone, no significant effects on plasma renin activity and natriuretic peptides, and a rise in vasopressin. Urocortin produced dose-dependent, sustained increases in urine volume (twofold, p < 0.01), sodium excretion (>9-fold rise, p < 0.001), and creatinine clearance (p < 0.001) in HF sheep. No significant renal effects were observed in normal sheep. CONCLUSIONS Urocortin has profound and sustained hemodynamic, hormonal, and renal effects in experimental HF. Urocortin may have a role in pressure/volume homeostasis in HF and may provide a novel therapeutic approach to this disease.

Integrated Hemodynamic, Hormonal, and Renal Actions of Urocortin 2 in Normal and Paced Sheep Beneficial Effects in Heart Failure

Background— Urocortin 2 (Ucn2) has potent cardiovascular actions and may participate in the pathophysiology of heart failure (HF). The integrated hemodynamic, endocrine, and renal effects of Ucn2 are unknown. Methods and Results— Eight sheep received incremental intravenous boluses of murine Ucn2 (10, 50, and 100 &mgr;g at 2-hour intervals) before (normal) and during pacing-induced HF. Compared with control data, Ucn2 induced rapid and dose-dependent increases in cardiac output (peak effects: normal 4.3±0.2 versus 6.1±0.2 L/min, P<0.001; HF 2.3±0.1 versus 4.5±0.2 L/min, P<0.001) and reductions in peripheral resistance (normal 20.2±1.0 versus 15.2±0.8 mm Hg/L per minute, P<0.01; HF 32.2±1.7 versus 13.6±0.5 mm Hg/L per minute, P<0.001) and left atrial pressure (normal 4.3±0.3 versus 0.5±0.2 mm Hg, P<0.01; HF 22.9±0.6 versus 5.1±1.8 mm Hg, P<0.001). Mean arterial pressure was minimally elevated in normals and decreased in HF (both P<0.01). In both states, Ucn2 reduced plasma atrial natriuretic peptide levels (normal 13±2 versus 10±2 pmol/L; HF 200±20 versus 72±10 pmol/L) and similarly increased corticotropin, cortisol, and Ucn1 (all P<0.001). In HF only, Ucn2 dose dependently decreased plasma vasopressin (3.09±0.36 versus 1.62±0.12 pmol/L, P<0.01), renin (2.98±1.17 versus 0.69±0.10 nmol/L per hour, P<0.001), aldosterone (1186±303 versus 364±122 pmol/L, P<0.001), endothelin-1 (3.39±0.23 versus 2.56±0.18 pmol/L, P<0.01), epinephrine (1633±260 versus 657±142 pmol/L, P<0.01), and brain natriuretic peptide (36±3 versus 18±4 pmol/L, P<0.001) concentrations. Renal effects, including increased urine volume (1.7-fold, P<0.05), sodium excretion (>12-fold, P<0.01), and creatinine excretion (1.3-fold, P<0.001), also occurred only in HF. Conclusions— Ucn2 has marked and beneficial hemodynamic, hormonal, and renal effects in experimental HF. These results support a role for Ucn2 in pressure/volume homeostasis in HF and suggest that the peptide may have therapeutic potential in this disease.

Combined neutral endopeptidase and angiotensin-converting enzyme inhibition in heart failure: role of natriuretic peptides and angiotensin II.

We examined for the first time the specific roles of angiotensin II and the natriuretic peptides during inhibition of angiotensin-converting enzyme (captopril, 25 mg bolus + 6 mg/3 h infusion) and endopeptidase 24.11 (SCH32615, 5 mg/kg bolus + 3 mg/kg/3 h infusion), both separately and in combination, in eight sheep with pacing-induced heart failure. Plasma atrial and brain natriuretic peptide levels were similarly increased by SCH32615 and to a lesser extent during combined inhibition but decreased with captopril. Captopril and combined inhibition induced identical increases in plasma renin activity and reductions in angiotensin II, whereas neither was changed by SCH32615 alone. Mean arterial pressure and peripheral resistance decreased during SCH32615 and further still during captopril and combined treatment. Left atrial pressure was reduced to a similar extent by SCH32615 and captopril alone and reduced further by combined inhibition. Cardiac output increased during all treatments. Urine volume and sodium excretion were significantly increased during SCH32615 and combined inhibition. Creatinine clearance increased during SCH32615, decreased during captopril, and was maintained during combined treatment. In conclusion, compared with captopril alone, cotreatment with an endopeptidase 24.11 inhibitor further improved filling pressures and induced a diuresis and natriuresis with preservation of renal glomerular filtration.

Increased cardiac sympathetic nerve activity following acute myocardial infarction in a sheep model

The time course of cardiac sympathetic nerve activity (CSNA) following acute myocardial infarction (MI) is unknown. We therefore undertook serial direct recordings of CSNA, arterial blood pressure (MAP) and heart rate (HR) in 11 conscious sheep before and after MI, and compared them with 10 controls. Conscious CSNA recordings were taken daily from electrodes glued into the thoracic cardiac nerves. Infarction was induced under pethidine and diazepam analgesia by applying tension to a coronary suture. MI size was assessed by left ventricular planimetry (%) at postmortem, peak troponin T and brain natriuretic peptide levels (BNP). Baroreflex slopes were assessed daily using phenylephrine‐nitroprusside ramps. The mean infarcted area was 14.4 ± 2.9%, troponin T 1.88 ± 0.39 μg l−1 and BNP 8.4 ± 1.3 pmol l−1. There were no differences in haemodynamic parameters or CSNA between groups at baseline. MAP and HR remained constant following MI. CSNA burst frequency increased from baseline levels of 55.8 ± 7.1 bursts min−1 to levels of 77.5 ± 8.7 bursts min−1 at 2 h post‐MI, and remained elevated for 2 days (P < 0.001). CSNA burst area also increased and was sustained for 7 days following MI (P= 0.016). Baroreflex slopes for pulse interval and CSNA did not change. CSNA increases within 1 h of the onset of MI and is sustained for at least 7 days. The duration of this response may be longer because the recording fields decrease with time. This result is consistent with a sustained cardiac excitatory sympathetic reflex.

Urotensin II: Evidence for cardiac, hepatic and renal production

Although urotensin II (UII) has been reported to circulate in human plasma and be raised in cardiovascular disorders, little, if any, information is available regarding the source of plasma UII. Accordingly, we have performed trans-organ arteriovenous sampling for measurement of UII concentration in anesthetized sheep. Plasma UII levels were measured in the low picomolar range in normal sheep and arterial plasma levels rose steadily with increasing time of anesthesia. Significant arteriovenous gradients were observed across the heart (36%), liver (40%) and kidney (44%). This is the first report to identify the heart, liver and kidney as sources of UII in the circulation.

Putative role for apelin in pressure/volume homeostasis and cardiovascular disease.

Apelin is a peptide recently isolated from bovine stomach extracts which appears to act as an endogenous ligand for the previously orphaned G-protein-coupled APJ receptor. The apelin gene encodes for a pre-propeptide consisting of 77 amino acids with mature apelin likely to be derived from the C-terminal region as either a 36, 17 or 13 amino acid peptide. Apelin mRNA expression and peptide immunoreactivity has been described in a variety of tissues including gastrointestinal tract, adipose tissue, brain, kidney, liver, lung and at various sites within the cardiovascular system. Apelin is strongly expressed in the heart with expression also present in the large conduit vessels, coronary vessels and endothelial cells. Message expression for the APJ receptor is similarly distributed throughout the brain and periphery, again including cardiovascular tissue. Consistent with this pattern of distribution, apelin and APJ have been shown to exhibit some role in the regulation of fluid homeostasis. In addition, a growing number of studies have reported cardiovascular actions of apelin. Not only has apelin been observed to alter arterial pressure, but the peptide also exhibits endothelium-dependent vasodilator actions in vivo and positive inotropic actions in the isolated heart. Furthermore, differences in apelin and APJ expression have been described in patients with congestive heart failure and circulating levels of apelin are also reported to change in heart failure. Taken together, these studies suggest a role for apelin in pressure/volume homeostasis and in the pathophysiology of cardiovascular disease. As such, manipulation of this peptide system may offer benefit to the syndrome of heart failure with potential clinical applications in humans.

The ovine hypothalamus and pituitary have markedly different distributions of C-type natriuretic peptide forms

C-type natriuretic peptide (CNP) was measured in the hypothalamus and pituitary of four sheep by radioimmunoassay after extraction. The mean concentration of CNP in the hypothalamus was 1.01 +/- 0.08 pmol/g and 45.8 +/- 12.8 pmol/g in the pituitary. Analysis of these extracts by size exclusion HPLC showed the presence of two immunoreactive CNP components that cochromatographed with porcine CNP-53 and CNP-22 standards. Similar amounts of CNP-53- and CNP-22-like IR-CNP were present in the ovine hypothalamus (ratio 0.9:1), whereas in the pituitary, the bulk of the immunoreactive CNP was in the CNP-53-like form. These results show major differences in the distribution of IR-CNP forms between the hypothalamus and pituitary, which may reflect differences in CNP prohormone processing in these two tissues.

Urotensin II in the cardiovascular system.

Urotensin II is a peptide present, together with its receptor, in the central nervous system and many peripheral tissues (including heart, blood vessels, kidneys and endocrine organs) of many species. The bioactive, mature form contains a cyclic heptapeptide perfectly preserved across species spanning 550 million years of evolution Its biological activity has been explored in cultured cells, in isolated vessels from several species, in the isolated perfused heart and in intact animals and man. Initial demonstration of potent vasoconstriction and cardiac depression by the human isoform in non-human primates has been followed by a series of reports indicating potent but highly variable and generally modest vascular responses dependent on species and vascular region. In man short term cardiovascular responses to administered urotensin II are small or absent. The place of urotensin II in the chronic trophic responses to cardiac and vascular injury and its possible roles as a neurotransmitter and/or regulator of renal and endocrine function remain largely unexplored.

Adrenomedullin and heart failure

Evidence suggests that adrenomedullin (AM) plays a role in the pathophysiology of heart failure. Circulating concentrations of AM are elevated in cardiovascular disease in proportion to the severity of cardiac and hemodynamic impairment. Raised plasma AM levels following acute cardiac injury and in heart failure provide prognostic information on adverse outcomes. In heart failure, elevated circulating AM also identifies patients likely to receive long-term benefit from inclusion of additional anti-failure therapy (carvedilol). Administration of AM in experimental and human heart failure induces reductions in arterial pressure and cardiac filling pressures, and improves cardiac output, in association with inhibition of plasma aldosterone (despite increased renin release) and sustained (or augmented) renal glomerular filtration and sodium excretion. Furthermore, AM in combination with other therapies (angiotensin-converting enzyme inhibition and augmentation of the natriuretic peptides) results in hemodynamic and renal benefits greater than those achieved by the agents separately. Manipulation of the AM system holds promise as a therapeutic strategy in cardiac disease.