Vijayan Menon

Vascular remodeling during healing after myocardial infarction in the dog model: Effects of reperfusion, amlodipine and enalapril

OBJECTIVES We sought to determine whether reperfusion and the calcium channel blocker amlodipine or the angiotensin-converting enzyme inhibitor enalapril, during healing over six weeks after myocardial infarction (MI), limit structural vascular remodeling in the noninfarct zone (NIZ). BACKGROUND The effect of reperfusion and amlodipine or enalapril on structural vascular remodeling during healing of MI has not been determined. METHODS We randomly assigned 54 dogs to reperfused or nonreperfused MI, followed by twice-daily doses of oral placebo, amlodipine (5 mg) or enalapril (5 mg) for six weeks and three days off treatment, or to three matching sham groups. We measured in vivo hemodynamic data and left ventricular (LV) function and remodeling (by echocardiography) over the six weeks, as well as ex vivo structural vascular, ventricular and collagen remodeling in the hearts after six weeks. RESULTS Compared with placebo and sham groups, both amlodipine and enalapril with or without reperfusion produced LV unloading and limited structural LV remodeling and dysfunction over six weeks in vivo, and also decreased the NIZ resistance vessel media/lumen area ratio at six weeks ex vivo. In addition, amlodipine, but not enalapril, preserved infarct scar collagen and increased the border zone collagen volume fraction and perivascular fibrosis, as well as NIZ resistance vessel media thickness. Enalapril, but not amlodipine, decreased transforming growth factor-beta in the border zone and NIZ. CONCLUSIONS The results indicate that therapy with amlodipine and enalapril during healing after reperfused MI limits structural vascular remodeling in the NIZ, probably by different mechanisms.

Postischemic apoptosis and functional recovery after angiotensin II type 1 receptor blockade in isolated working rat hearts.

Objective To determine whether chronic angiotensin (AngII) type I receptor (AT1R) blockade inhibits cardiomyocyte (CM) apoptosis and attenuates left ventricular (LV) dysfunction after ischemia–reperfusion (IR) in the isolated working rat heart. Methods Postischemic recovery of LV developed pressure, the apoptotic index (terminal deoxynucleotidyl transferase (TdT)-mediated dUTP in situ nick end labeling or TUNEL assay), and changes in expression of apoptotic markers Bcl-2, Bax, p53 and caspase-3 (Western immunoblots) were measured after IR (50 min aerobic perfusion; 25 min global ischemia; 40 min reperfusion) in working rat hearts that were randomized to five groups of six each along 1 week or 3 week pretreatment arms: sham (no drug, no perfusion); no drug, aerobic perfusion; and oral AT1R blockers losartan (30 mg/kg per day) or UP269-6 (3 mg/kg per day), or no drug before IR. Results Compared to the no drug group after IR, losartan (not UP269-6) preserved functional recovery in 1 and 3 week groups. However, both losartan and UP269-6 reduced the apoptotic index and normalized the increase in Bax, decrease in Bcl-2 and increase in p53 and caspase-3 after IR. A bell-shaped relation between apoptosis and functional recovery after IR was flattened by AT1R blockade. Conclusion The results indicate that IR is associated with LV dysfunction and CM apoptosis involving activation of p53, caspase-3, and increased Bax/Bcl-2 ratio in the working rat heart. Importantly, chronic AT1R blockade inhibited the apoptosis and changes in expression of the markers without improving functional recovery, implying that decrease in apoptosis does not necessarily translate into decreased LV dysfunction.

AT1 Receptor blockade limits myocardial injury and upregulates AT2 receptors during reperfused myocardial infarction

Persistent left ventricular (LV) dysfunction after reperfused myocardial infarction (RMI) is a significant problem and angiotensin II (AngII) type 1 receptor (AT1R) blockers (ARBs) may limit reperfusion injury involving upregulation of AngII type 2 receptors (AT2R). To determine whether ARBs valsartan and irbesartan limit reperfusion injury and upregulate AT2R protein during RMI, we randomized dogs with anterior RMI (90 min ischemia; 120 min reperfusion) to 4 groups [valsartan (n = 6); irbesartan (n = 9); vehicle controls (n = 8); and sham (n = 6)] and measured serial in vivo hemodynamics, LV systolic and diastolic function, and inhibition of AngII pressor responses to the ARBs, and ex vivo infarct size, and regional AT1R and AT2R protein expression at the end of the reperfusion. Compared to the control group, both ARBs significantly limited the increase in left atrial pressure, promptly limited the deterioration of LV dP/dtmax, dP/dtmin, ejection fraction and diastolic function, limited infarct expansion and thinning, and limited infarct size. Importantly, both ARBs increased AT2R protein in the postischemic reperfused zone, with no change in AT1R protein. There were no changes in the sham group. The results suggest that limitation of myocardial injury associated with AT1R blockade combined with upregulation of AT2R protein expression contributes to the cardioprotective effects of ARBs during RMI. This beneficial effect of ARBs on persistent LV dysfunction after RMI should be evaluated in the clinical setting to determine the relative benefit of ARBs in patients who undergo reperfusion therapy for acute coronary syndromes.

Valsartan-induced cardioprotection involves angiotensin II type 2 receptor upregulation in dog and rat models of in vivo reperfused myocardial infarction

BACKGROUND Cardioprotection with angiotensin II (AngII) type 1 receptor (AT(1)R) blockade was associated with AngII type 2 receptor (AT(2)R) upregulation and activation during in vivo reperfused myocardial infarction (RMI) in dogs, but it is unclear whether this occurs in rats. Methods and results In vivo hemodynamics, left ventricular (LV) function, infarct size, and AT(1)R/AT(2)R protein (immunoblots) after anterior RMI were measured in rats (60 minutes ischemia, 90 minutes reperfusion, n=30) and dogs (90 minutes ischemia, 120 minutes reperfusion, n=22) randomized to pretreatment with valsartan (10 mg/kg, intravenously) or vehicle control, and vehicle sham groups. AT(1)R blockade was confirmed by inhibition of AngII pressor responses at the dose used. Compared with dog and rat controls, valsartan decreased infarct size (52 versus 31% and 47 versus 33%, respectively), improved left ventricular ejection fraction (-32 versus -14% and -46 versus -21%, respectively), limited infarct expansion and infarct thinning, and improved diastolic function after RMI. In both species, AT(2)R protein in the infarct zone decreased in controls and increased with valsartan. Sham animals showed no changes. CONCLUSIONS AT(1)R blockade with valsartan induces short-term cardioprotection associated with enhanced AT(2)R expression in both dog and rat models of in vivo RMI.

Cardioprotective effects of angiotensin II type 1 receptor blockade with candesartan after reperfused myocardial infarction: role of angiotensin II type 2 receptor

To determine whether angiotensin II (Ang II) type 2 (AT2)-receptor activation associated with cardioprotection induced by Ang II type 1 (AT1)-receptor blockade during ischaemia-reperfusion (IR) might be reflected in increased AT 2-receptor, IP3-(1,4,5- inositol trisphosphate type 2) receptor and PKC-ε (protein kinase C-ε) proteins and tissue cGMP (cyclic guanosine monophosphate), we measured in vivo left ventricular (LV) systolic and diastolic function and remodelling (echocardiogram/Doppler) and haemodynamics, and ex vivo infarct size, AT1-/AT 2receptor, IP3-receptor and PKC-ε proteins (immunoblots) and cGMP (enzyme immunoassay) in dogs with reperfused anterior acute myocardial infarction (MI) (90-minute ischaemia, 120-minute reperfusion). Compared with controls (C, n=6) in vivo, candesartan (1 mg/kg i.v. over 30-minute pre-ischaemia, n=6) effectively inhibited the Ang II pressor response (Δ%, -14±22% vs. -80±11, p<0.003) and decreased preload (122±35 vs. -2±16%, p<0.01), improved LV systolic ejection fraction (-29±4 vs. -11±5, p<0.03) and diastolic function (E/A ratio, -25±7 vs. 33±13, p<0.004), decreased the extent of LV asynergy (26±20 vs. -31±10% LV, p<0.05) and limited acute LV remodelling (expansion index 19±6 vs. -3±5, p<0.05; thinning ratio -22±2 vs. -4±2, p<0.0003). Ex vivo, candesartan decreased infarct size (55±2 vs. 27±2% risk, p<0.001) and increased infarct zone (IZ) AT2 -receptor protein by 8-fold (but not AT1-receptor protein), IP3-receptor protein by 12-fold, PKC-ε protein by 5-fold and cGMP by 40%. Cardioprotective effects of AT1-receptor blockade on acute IR injury, LV function, and remodelling may also involve AT 2-receptor activation and downstream signalling via IP3-receptor, PKC-ε and cGMP.

AT2 receptor and apoptosis during AT1 receptor blockade in reperfused myocardial infarction in the rat.

We assessed whether upregulation of the angiotensin II (AngII) type 2 receptor (AT2R) during AngII type 1 receptor (AT1R) blockade might induce apoptosis in the in vivo rat model of reperfused myocardial infarction (RMI) and whether addition of an AT2R blocker abolishes that effect. We measured in vivo hemodynamics and left ventricular (LV) systolic and diastolic function (echocardiograms/Doppler), and ex vivo infarct size (triphenyl tetrazolium chloride), regional AT1R and AT2R proteins (immunoblots), and apoptosis (TUNEL assay and DNA ladder) after regional anterior RMI (60 min ischemia, 90 min reperfusion) in Sprague-Dawley rats randomized to intravenous AT1R blockade with candesartan (1 mg/kg, n= 9) or saline (controls, n= 14) over 30 min before RMI, and sham (n= 8). We also assessed the effect of AT2R blockade (PD123319, 10 mg/kg i.v.) plus candesartan on infarct size and apoptosis. Compared to controls, candesartan significantly (p < 0.001) limited increases in left atrial pressure, improved positive LV dP/dtmax and negative dP/dtmin, normalized LV ejection fraction, improved LV diastolic function, limited infarct expansion, decreased infarct size and apoptosis, and increased AT2R protein (not AT1R) in the reperfused ischemic zone. There were no changes in sham hearts. PD123319 abolished the candesartan-induced decrease in infarct size and LV dysfunction but not the decrease in apoptosis. Thus, during AT1R blockade in the in vivo rat model of RMI, regional AT2R upregulation contributes to the beneficial effect on infarct size and LV dysfunction but not on apoptosis, suggesting that the apoptosis is AT1R not AT2R-mediated. (Mol Cell Biochem 262: 203–214, 2004)

Effect of angiotensin II type 2 receptor blockade on mitogen activated protein kinases during myocardial ischemia-reperfusion.

Mitogen-activated protein kinases (MAPKs) have been implicated during ischemia-reperfusion (IR) and angiotensin II (AngII) type 2 receptor (AT2R) blockade has been shown to induce cardioprotection involving protein kinase Cε-(PKCε) signaling after IR. We examined whether the 3 major MAPKs, p38, c-Jun NH2-terminal kinase (JNK-1 and JNK-2), and extracellular signal regulated kinases (ERK-1 and ERK-2) are activated after IR and whether treatment with the AT2R antagonist PD123,319 (PD) alters their expression. Isolated rat hearts were randomized to control (aerobic perfusion, 80 min), IR (no drug; 50 min of perfusion, 30 min global ischemia and 30 min reperfusion; working mode), and IR + PD (0.3 μmol/l) and left ventricular (LV) work was measured. We measured LV tissue content of p38, p-p38, p-JNK-1 (54 kDa), p-JNK-2 (46 kDa), p-ERK-1 (44 kDa), p-ERK-2 (42 kDa) and PKCε proteins by immunoblotting and cGMP by enzyme immunoassay. IR resulted in significant LV dysfunction, increase in p-p38 and p-JNK-1/-2, no change in p-ERK-1/-2 or PKCε, and decrease in cGMP. PD improved LV recovery after IR, induced a slight increase in p-p38 (p < 0.01 vs. control), normalized p-JNK-1, did not change p-ERK-1/-2, and increased PKCε and cGMP. The overall results suggest that p38 and JNK might play a significant role in acute IR injury and the cardioprotective effect of AT2R blockade independent of ERK. The activation of p38 and JNKs during IR may be linked, in part, to AT2R stimulation.

Upregulation of Angiotensin II Type 2 Receptor and Limitation of Myocardial Stunning by Angiotensin II Type 1 Receptor Blockers during Reperfused Myocardial Infarction in the Rat

Background: We have previously shown that angiotensin II type 1 receptor blockers induce cardioprotection and upregulate angiotensin II type 2 receptor during in vivo postischemicreperfusion in dogs. Whether angiotensin II type 1 receptor blockers upregulate angiotensin II type 2 receptors in rats is controversial, and whether surmountable and insurmountable angiotensin II type 1 receptor blockers exert similar protective effects during reperfused myocardial infarction is not known. Methods: We assessed the effects of the surmountable angiotensin receptor blocker valsartan, and the insurmountable angiotensin receptor blocker irbesartan, on hemodynamics and left ventricular systolic and diastolic function (echocardiography/Doppler) in vivo and infarct size (triphenyl tetrazolium chloride method), and regional angiotensin II type 1 receptor and angiotensin II type 2 receptor expression (immunoblots) ex vivo, after anterior reperfused myocardial infarction in rats. The rats were randomized to four groups: intravenous valsartan (10 mg/kg, n = 8), irbesartan (10 mg/kg, n = 8), or saline vehicle (controls, n = 14) over 30 minutes before reperfused myocardial infarction, and sham (n = 8). Angiotensin II type 1 receptor blockade was assessed by the inhibition of angiotensin II pressor responses. Results: Compared with the control group, both angiotensin receptor blockers significantly decreased infarct size, limited the increase in left atrial pressure, improved positive left ventricular dP/dtm,x and dP/dtm,,, improved left ventricular ejection fraction and diastolic function, and limited infarct expansion after reperfused myocardial infarction. Both angiotensin receptor blockers increased angiotensin II type 2 receptor protein in the postischemic-reperfused zone, with no change in angiotensin II type 1 receptor protein. There were no changes in the sham group. Conclusion: The overall results indicate that the angiotensin receptor blockers valsartan and irbesartan both induce cardioprotection, limit myocardial stunning, and upregulate angiotensin II type 2 receptor protein expression after reperfused myocardial infarction in the rat. Patients who are already receiving angiotensin receptor blockers and develop acute coronary syndromes might benefit from these cardioprotective effects during reperfusion therapy.

Effect of Angiotensin II lype 2 Receptor Blockade on Activation of Mitogen-Activated Protein Kinases after Ischemia-Reperfusion in Isolated Working Rat Hearts

Background: The stress-responsive mitogen-activated protein kinases (MAPKs) (p38-MAPK, c-Jun NH2-terminal kinase [JNK-1 and JNK-2], and extracellular signal regulated kinases [ERK-1 and ERK-2]) might be involved in angiotensin II (AIJ)-induced ischemiareperfusion injury. Cardioprotection induced by All type 1 (AT1) and type 2 (AT2) receptor blockade during ischemia-reperfusion is associated with protein kinase Cc (PKCe), nitric oxide, and cyclic guanosine monophosphate (cGMP) signaling. Our aim was to assess the effect of selective AT, and AT2 receptor blockade with losartan and PD123,319, respectively, on MAPK expression after ischemia-reperfusion in isolated working rat hearts. Methods: Groups of six hearts were subjected to global ischemia (30 minutes) followed by reperfusion (30 minutes) and exposed to no drug/no ischemia-reperfusion (control), ischemia-reperfusionlno drug, and ischemia-reperfusion with losartan (1 MM), or PD123,319 (0.3,uM) and additional groups. AT,/AT2 receptor expression, MAPKs, PKCE, and cGMP, and changes in mechanical function were measured. Western blotting was done on left ventricular tissue for AT,/AT2, p38/phosphorylated-p38 (p-p38), phosphorylated (p)-JNK-1/-2, phosphorylated (p)-ERK-1/-2, and PKCe proteins; Northern blots for AT,/AT2 mRNA; and enzyme immunoassay for cGMP. Results: Compared with controls, ischemia-reperfusion induced significant left ventricular dysfunction, decreased AT2 protein and mRNA, increased p-p38 and p-JNK-1/-2, did not change p-ERK-1/-2 or PKCe, and decreased cGMP. PD123,319 improved left ventricular recovery after ischemia-reperfusion, increased AT2 protein and mRNA, mildly increased p-p38, normalized p-JNK-1, did not change p-ERK-1/-2, and increased PKCe and cGMP. Losartan did not change p-p38, increased p-JNK-1, and did not change pERK- 1/-2, PKCe, or cGMP. Conclusions: The overall results suggest that the activation of p38-MAPK and JNK might be linked to All signaling and play a significant role in acute ischemia-reperfusion injury as well as in the cardioprotective effect of AT2 receptor blockade.

Beneficial Effects of Therapy on the Progression of Structural Remodeling During Healing After Reperfused and Nonreperfused Myocardial Infarction: Different Effects on Different Parameters

Background: Structural left ventricular remodeling after myocardial infarction is a complex process with several pathophysiologic descriptors that can be modified by pharmacotherapy. However, the possibility that different classes of antiremodeling agents might exert different effects on different remodeling parameters after reperfused and nonreperfused myocardial infarction has not been systematically studied. Methods and Results: We measured detailed left ventricular remodeling parameters in vivo (echocardiograms) repeatedly over 6 weeks and ex vivo (planimetry) at 6 weeks after myocardial infarction in 36 dogs randomized (factorial design) after reperfused or nonreperfused myocardial infarction to 6 weeks of twice daily oral therapy with the calcium channel blocker amlodipine (5 mg), the angiotensin-converting enzyme inhibitor enalapril (5 mg) or placebo, and 18 matching sham or control animals. Compared to placebo and control groups over 6 weeks, both agents reduced left ventricular loading and limited overall remodeling in both reperfused and nonreperfused groups, but there were pertinent differences. Enalapril limited the increase in left ventricular asynergy in the reperfused group. Both enalapril and amlodipine limited infarct zone thinning in the nonreperfused groups but increased infarct zone thinning in the reperfused groups, despite preserved infarct zone collagen with amlodipine. Enalapril decreased left ventricular diastolic volume and mass more than amlodipine in the reperfused group and increased left ventricular ejection fraction in the nonreperfused group. Both agents limited regional and global shape deformation in reperfused and nonreperfused groups. Diastolic wall stress in the infarct zone decreased with amlodipine, and increased with enalapril and reperfusion. Conclusions: Different antiremodeling therapies may exert different effects on different remodeling parameters during healing after reperfused myocardial infarction. Significant interactions occur during reperfusion. More than one variable may be needed for the comprehensive assessment of the antiremodeling efficacy of different therapies.