Magnesium and cardiovascular disease

Differential effects of extracellular Mg2+ on thrombin-induced and capacitative Ca2+ entry in human coronary arterial endothelial cells

Receptor-mediated and capacitative Ca2+ entry are the primary Ca2+ entry pathways in endothelial cells (ECs). The mechanisms for Ca2+ entry via these pathways have not been fully elucidated. In this study, the effect of low and high external Mg2+ concentrations on these Ca2+ entry pathways was examined in human coronary arterial ECs. External Mg2+ concentration did not affect cytosolic free Mg2+ concentration. After exposure to thrombin in Ca(2+)-free medium, addition of Ca2+ to the medium caused a rise in cytosolic free Ca2+ concentration ([Ca2+]i), indicating thrombin-induced Ca2+ influx. Thrombin-induced Ca2+ influx was inhibited by not only low but also high external Mg2+ concentrations. After depletion of endoplasmic Ca2+ stores by thapsigargin, addition of Ca2+ to the medium induced an increase in [Ca2+]i, indicating capacitative Ca2+ entry. Capacitative entry was found to be accelerated by low external Mg2+ and inhibited by high external Mg2+ concentration. Results suggest that receptor-mediated Ca2+ influx requires external Mg2+ but is inhibited by increased external Mg2+ concentrations and that capacitative Ca2+ entry is reduced by external Mg2+ in human coronary arterial ECs.

Magnesium deficiency enhances oxidative stress and collagen synthesis in vivo in the aorta of rats

Magnesium deficiency has been shown to produce vascular lesions in experimental animals, but the underlying mechanisms of vascular injury are not clear. It has been reported that in rodents, magnesium deficiency enhances circulating levels of factors that promote free radical generation and are mitogenic. In pursuance of these observations, the present study tested the hypothesis that magnesium deficiency may enhance oxidative stress and trigger an accelerated growth response in vivo in the aorta of rats. Oxidative stress was evaluated in terms of levels of thiobarbituric acid-reactive substances in the serum and aorta and activity of superoxide dismutase and catalase in the aorta; fractional rates of collagen synthesis were assessed using [3H]-proline. Serum and tissue levels of magnesium and calcium were determined by atomic absorption spectrophotometry. The present study demonstrated for the first time that magnesium deficiency significantly (P < 0.001) increases levels of thiobarbituric acid-reactive substances in the aorta of rats. Other changes in the aorta of animals on the Mg-deficient diet included a significant reduction (54%, P < 0.001) in the activity of superoxide dismutase and catalase (37%, P < 0.01) and a 19% increase in net fractional rates of collagen synthesis (P < 0.05). While serum magnesium was significantly reduced in these animals (P < 0.001), aortic tissue levels of magnesium in these animals remained unaltered throughout the duration of the study, suggesting the existence of other control mechanisms, apart from reduced tissue levels of magnesium, mediating the observed effects. These findings suggest that magnesium deficiency may trigger a wound healing response, involving oxidative injury and growth stimulation, in the vascular system.

Depressed antioxidant defense in rat heart in experimental magnesium deficiency. Implications for the pathogenesis of myocardial lesions

Magnesium (Mg) deficiency has been shown to produce myocardial lesions in different experimental models. Based on several lines of evidence, it has been proposed that oxidative injury to the cardiac muscle may explain the pathobiology of such lesions. In pursuance of this postulation, the present study examined the effect of dietary deficiency of Mg on the activity of the antioxidant enzymes, superoxide dismutase (SOD) and catalase, in rat heart. This article reports a significant lowering of the activity of both these enzymes in the cardiac tissue in Mg-deficient rats. Since depressed antioxidant defense in the heart may enhance myocardial susceptibility to oxidative injury, the observation is of possible relevance to the pathogenesis of cardiac lesions in Mg deficiency.

Magnesium sulfate solution dramatically improves immediate recovery of rats from hypoxia

This study in rats investigated the effects of 0.5 mEq/1 kg body weight of magnesium sulfate solution upon hypoxic left cardiac ventricular pressure (Part 1), optimal timing for injection of magnesium sulfate solution for successful resuscitation (Part 2) and survival benefits of magnesium sulfate after 8 or 12 min of hypoxia (Part 3) in rats resuscitated by single bolus arterial reperfusion using 2 ml of arterial blood and 6-9 micrograms epinephrine. A total of 153 pentobarbital anesthetized rats were subjected to 8 or 12 min 0.75% O2:99.25% N2 hypoxia in order to induce cardiac arrest. In Part 1, 13 rats (six control and seven injected with magnesium sulfate solution) were subjected to 12 min hypoxia and cardiac left ventricular pressure (LVP) was measured. In Part 2, 47 rats were exposed to 12 min of hypoxia. Normal saline or magnesium sulfate solution was injected prior to hypoxia, at 2 or 4 min of hypoxia, to find the optimal timing of magnesium sulfate injection for successful resuscitation by arterial reperfusion. In Part 3, 90 rats were studied to determine 7-day survival. Two control groups were injected with saline during 8 min (29 rats) or 12 min (18 rats) of hypoxia and two groups received magnesium sulfate solution during 8 min (14 rats) and 12 min (29 rats) of hypoxia. Magnesium sulfate fully reversed the hypoxic increase of LVP and improved survival after 12 min of hypoxia from approximately 15 (control) to 100% if given during the first 2.5 min of hypoxia. The main cause of the progressive resuscitation failure after 8 or 12 min control hypoxia was a progressive increase in acute cardiac failure. Although magnesium sulfate solution significantly improved immediate recovery after hypoxia (8 and 12 min), mortality due to reperfusion injury (para or tetraplegia) was observed in 62% of rats surviving longer than 1 day after 8 min and 100% after 12 min hypoxia (in control rats-50 and 100%, respectively). The overall survival after hypoxia, with or without reperfusion injury, was relatively low: 28% in control groups after 8 min and 17% after 12 min. In the magnesium sulfate groups these numbers were only slightly higher, 36 and 21%, respectively. It is concluded that in conjunction with arterial reperfusion magnesium sulfate infusion is very effective in improving acute cardiac recovery after 8-12 min of hypoxia. The likely mechanism of magnesium sulfate action is decreased incidence of ventricular fibrillation (VF) and asystole, and possibly myocardial relaxation during and after hypoxia, a property which may qualify MgSO4 as an ischemic preconditioning agent. Poor long-term survival rates of rats exposed to hypoxia and resuscitated by intraarterial reperfusion do not support its use in resuscitation.

Extracellular Mg2+ inhibits capacitative Ca2+ entry in vascular smooth muscle cells

BACKGROUND

Agonist-induced Ca2+ entry is thought to be mediated by capacitative Ca2+ entry other than L-type Ca2+ channels in vascular smooth muscle cells (VSMCs). The mechanism for capacitative Ca2+ entry has not been fully elucidated. Our objective was to examine the effect of external Mg2+ on capacitative Ca2+ entry in cultured rat aortic VSMCs.

METHODS AND RESULTS

Three doses of external Mg2+ concentration (nominally 0, 1, and 5 mmol/L) were used. After exposure to 1 mumol/L, angiotensin II (Ang II) in Ca(2+)-free medium, addition of Ca2+ to the medium caused an increase in cytosolic free Ca2+ concentration ([Ca2+]i), indicating Ang II-induced Ca2+ influx. This Ca2+ influx was attenuated in cells preincubated with high external Mg2+ concentrations or with 1 mumol/L nifedipine. After VSMCs in Ca(2+)-free medium were exposed to 1 mumol/L thapsigargin, which inhibits the sarcoplasmic reticulum Ca(2+)-ATPase and depletes Ca2+ stores, addition of Ca2+ to the medium induced an increase in [Ca2+]i, indicating capacitative Ca2+ entry. This entry pathway was found to be independent of dihydropyridine-sensitive Ca2+ channels and inhibited by increased external Mg2+ concentration. External Mg2+ concentration did not influence Ca2+ efflux across the plasma membrane after stimulation with Ang II plus thapsigargin.

CONCLUSIONS

Results suggest that in VSMCs, capacitative Ca2+ entry is reduced by external Mg2+. This mechanism may explain in part the inhibitory effect of external Mg2+ on Ca2+ handling.

Acute myocardial infarction without thrombolytic therapy: beneficial effects of magnesium sulfate

Only one third of hospitalized patients with acute myocardial infarction (AMI) receive thrombolytic therapy despite its proven benefits on outcomes. Elderly patients, have a greater risk of death during myocardial infarction; however, thrombolytic therapy appears to be less used in these patients, as compared to the general AMI-patients. In order to evaluate the impact of magnesium supplementation in AMI-patients without thrombolytic therapy, 194 patients participated in a prospective, randomized and placebo-controlled study: 96 patients received a 48-hour intravenous magnesium sulfate and 98 isotonic glucose as placebo. Magnesium infusion reduced the incidence of arrhythmias, congestive heart failure and in-hospital-mortality compared with placebo (27 vs. 40%, p = 0.04; 18 vs. 23%, p = 0.27; 4 vs. 17%, p < 0.01, respectively); in the subgroup of elderly patients (> 70 years), the benefit was also obvious (42 vs. 50%; 18 vs. 25%; 9 vs. 23%, p = 0.09, respectively). These data suggest that intravenous magnesium supplementation might be justified in order to reduce myocardial damage and mortality rate in subsets of high-risk patients such the elderly and/or patients not suitable for thrombolysis. Additional trials appear to be indicated to evaluate the potential benefit of magnesium in well defined specific subsets of AMT-patients.

Antiarrhythmic effects of increasing the daily intake of magnesium and potassium in patients with frequent ventricular arrhythmias. Magnesium in Cardiac Arrhythmias (MAGICA) Investigators

OBJECTIVES

This study sought to assess potential antiarrhythmic effects of an increase in the daily oral intake of magnesium and potassium in patients with frequent ventricular arrhythmias.

BACKGROUND

Magnesium and potassium contribute essentially to the electrical stability of the heart. Despite experimental and clinical evidence for the antiarrhythmic properties of the two minerals, controlled data in patients with stable ventricular arrhythmias are lacking.

METHODS

In a randomized, double-blind study, 232 patients with frequent ventricular arrhythmias (> 720 ventricular premature beats [VPBs]/24 h) confirmed at baseline and after 1 week of placebo therapy were subsequently treated over 3 weeks with either 6 mmol of magnesium/12 mmol of potassium-DL-hydrogenaspartate daily or placebo.

RESULTS

Compared with placebo pretreatment, active therapy resulted in a median reduction of VPBs by -17.4% (p = 0.001); the suppression rate was 2.4 times greater than that in patients randomized to 3 weeks of placebo therapy (-7.4%, p = 0.038). The likelihood of a > or = 60% (predefined criterion) or > or = 70% suppression rate (calculated from the placebo-controlled run-in period) was 1.7 (25% vs. 15%, p = 0.044) and 1.5 times greater in the active than in the placebo group (20% vs. 13%, p = 0.085), respectively. No effect of magnesium and potassium administration was observed on the incidence of repetitive and supraventricular arrhythmias and clinical symptoms of the patients.

CONCLUSIONS

To our knowledge, this study is the first to provide controlled data on the antiarrhythmic effect of oral administration of magnesium and potassium salts when directed to patients with frequent and stable ventricular tachyarrhythmias. A 50% increase in the recommended minimum daily dietary intake of the two minerals for 3 weeks results in a moderate but significant antiarrhythmic effect. However, with the given therapeutic regimen, repetitive tachyarrhythmias and patient symptoms remain unchanged.

Magnesium deficiency-related changes in lipid peroxidation and collagen metabolism in vivo in rat heart

Magnesium deficiency is known to produce a cardiomyopathy, characterised by myocardial necrosis and fibrosis. As part of the ongoing investigations in this laboratory to establish the biochemical correlates of these histological changes, the present study probed the extent of lipid peroxidation and alterations in collagen metabolism in the heart in rats fed a magnesium-deficient diet for 28, 60 or 80 days. While lipid peroxidation was measured by the thiobarbituric acid reaction, collagen turnover rates and fibroblast proliferation were assessed using [3H]-proline and [3H]-thymidine, respectively. Tissue levels of magnesium and calcium were determined by atomic absorption spectrophotometry. A 39% increase in the cardiac tissue level of thiobarbituric acid reactive substances was observed on day 60 of deficiency (p < 0.001). A marked drop in collagen deposition rate (59%, p < 0.001%) on day 28 but a significant rise in fractional synthesis rate (12%, p < 0.001) and collagen deposition rate (24%, p < 0.001) on day 60 were observed. A fibroproliferative response in the heart was evident on day 80 but not at earlier time-points. Thus, the present study provides evidence of increased lipid peroxidation and net deposition of collagen in the myocardium in response to dietary deficiency of magnesium. These changes were, however, not directly related to alterations in the tissue levels of Mg. It is suggested that the increase in cardiac collagen synthesis and fibroplasia associated with Mg deficiency may represent reparative fibrogenesis, upon oxidative damage to the cardiac muscle, and is mediated by a mechanism independent of changes in cardiac tissue levels of Mg.

Cisplatinum enhancement of myocardial Mg2+ transport

Cisplatinum in a concentration (4.3 x 10(-6) M) corresponding to the therapeutic plasma concentration for cancer patients was found to cause a marked enhancement of magnesium efflux and uptake in perfused frog myocardium. The magnesium content of the perfused frog ventricle is increased from 6.66 +/- 0.34 mumol/g wet wgt to 8.03 +/- 0.38 mu mol/g wet wgt. Cisplatinum had a negative inotropic action reducing contractile force to 46 +/- 8% of initial force after 40 min of perfusion. The corresponding control contractile force was reduced to 74 +/- 7%. Removal of calcium and magnesium from the perfusion solution containing 0.5 mM EDTA for 10 minutes caused contractile force to be reduced to 0 after 6 beats at 24 min-1. After ten minutes of perfusion with EDTA, 1.87 mu mol/g wet wgt of magnesium was lost from control ventricles. Cisplatinum increased the loss to 4.08 +/- 0.34 mu mol/g wet wgt. The magnesium lost during EDTA perfusion was completely recovered after 5 minutes of perfusion in Ringer or Tyrode solution by both control and cisplatinum treated frog ventricles. The contractile force also recovered to the level prior to perfusion with EDTA Ringer. The rate of Mg2+ efflux in EDTA Ringer is largest during the first 3 minutes and was 0.170 +/- 0.051 p mol cm-2 sec-1 for controls and 0.798 p mol cm-2 sec-1 for the cisplatinum treated ventricles. During the last 7 min of perfusion in EDTA Ringer the Mg2+ efflux was reduced to 0.057 +/- 0.005 p mol cm-2 sec-1 for control ventricles and 0.170 p mol cm-2 sec-1 for the cisplatinum treated ventricles. Cisplatinum increased both magnesium efflux and influx and influx in the frog myocardium, increased magnesium content to a higher level and reduced contractile force. The effect of cisplatinum on magnesium transport is attributed to an increase in the charged form of cisplatinum that accumulates inside the cell where chloride content is low and the chloride of cisplatinum is displaced to form a positively charged cisplatinum.

Significance of magnesium in congestive heart failure

Electrolyte balance has been regarded as a factor important to cardiovascular stability, particularly in congestive heart failure. Among the common electrolytes, the significance of magnesium has been debated because of difficulty in accurate measurement and other associated factors, including other electrolyte abnormalities. The serum magnesium level represents < 1% of total body stores and does not reflect total-body magnesium concentration, a clinical situation very similar to that of serum potassium. Magnesium is important as a cofactor in several enzymatic reactions contributing to stable cardiovascular hemodynamics and electrophysiologic functioning. Its deficiency is common and can be associated with risk factors and complications of heart failure. Typical therapy for heart failure (digoxin, diuretic agents, and ACE inhibitors) are influenced by or associated with significant alteration in magnesium balance. Magnesium therapy, both for deficiency replacement and in higher pharmacologic doses, has been beneficial in improving hemodynamics and in treating arrhythmias. Magnesium toxicity rarely occurs except in patients with renal dysfunction. In conclusion, the intricate role of magnesium on a biochemical and cellular level in cardiac cells is crucial in maintaining stable cardiovascular hemodynamics and electrophysiologic function. In patients with congestive heart failure, the presence of adequate total-body magnesium stores serve as an important prognostic indicator because of an amelioration of arrhythmias, digitalis toxicity, and hemodynamic abnormalities.

Magnesium in acute myocardial infarction: overview of available evidence

Despite improvements in the outcome of patients with acute myocardial infarction (MI) during the past three decades, room for improvement exists in elderly patients and in patients who are not candidates for thrombolysis. Animal models suggest that magnesium supplementation before reperfusion reduces infarct size. Statistical analysis of the randomized trials of magnesium in MI reveals a gradient of response. When higher risk patients were enrolled, a greater benefit of magnesium was observed; progressively smaller benefits of magnesium occurred as the control group mortality approached 7%, at which point no benefit was detected. Although the ISIS-4 study enrolled more than 58,000 patients, no reduction in mortality was seen, probably as a result of a low control group mortality and relatively late administration of the magnesium. Because the potential benefit of magnesium in MI remains an open question, additional trials are needed before this inexpensive and easily administered therapy is prematurely cast aside.

Potentiation of the intracellular Ca2+ response to arginine vasopressin by increased cytosolic-free Mg2+ in rat vascular smooth muscle cells

Although the inhibitory effects of extracellular Mg2+ on Ca2+ influx are well established, little is known about the effects of intracellular Mg2+ on Ca2+ handling. In the present study, the effects of cytosolic-free Mg2+ concentration in the physiological (submillimolar) range on Ca2+ handling were investigated after stimulation of rat vascular smooth muscle cells with arginine vasopressin. Cytosolic Mg2+ was manipulated by culturing cells in medium containing different Mg2+ concentrations. Peak cytosolic-free Ca2+ concentration responses to arginine vasopressin (1 mumol/1) were measured in the presence and absence of external Ca2+. The results suggest that an increase in cytosolic-free Mg2+ concentration increases both Ca2+ discharge from intracellular stores and Ca2+ influx, whereas a decrease in intracellular Mg2+ attenuates Ca2+ influx.

Hypomagnesemia: characterization of a model of sudden cardiac death

OBJECTIVES

We sought to compare the incidence of sudden death in rats treated with magnesium-deficient and control diets and to address the electrophysiologic characteristics associated with these end points.

BACKGROUND

Although magnesium deficiency is associated with an increased incidence of sudden cardiac death in patients, there has been no clear cause and effect relation because of a number of covariables, including diuretic use, hypokalemia, digitalis use and left ventricular dysfunction.

METHODS

Hypomagnesemic rats and their paired control rats underwent in vivo electrophysiologic studies and measurements of the total calcium and magnesium content of their cardiac ventricles

RESULTS

Serum magnesium levels were 0.5 +/- 0.3 mEq/liter (mean +/- SD) in hypomagnesemic animals and 1.2 +/- 0.9 mEq/liter in control animals. A modest but significant prolongation of the repolarization time was seen at the apical epicardial site (83 +/- 8 ms in hypomagnesemic rats vs. 68 +/- 13 ms in control rats, p < 0.05), but not at the other sites studied. Bradyarrhythmias and tachyarrhythmias were observed in 82% of the hypomagnesemic rats during the in vivo electrophysiologic studies, compared with 0% in the control group. During these studies, sudden, unexpected asystolic deaths were observed in 4 of 11 hypomagnesemic rats and 0 of 8 control rats. Polymorphic nonsustained ventricular tachycardia was provoked by rapid pacing in 5 to 11 hypomagnesemic rats and 0 of 8 control rats. Three of six hypomagnesemic rats exposed to auditory stimuli developed seizures, followed immediately by sudden deaths-two due to asystole and one due to ventricular fibrillation-although no end points occurred in the control animals.

CONCLUSIONS

In this model, magnesium deficiency results in sudden cardiac death. The presence of startle induction of sudden death preceded by seizures suggests that sudden cardiac death results from a neurologic trigger.

Magnesium repletion and its effect on potassium homeostasis in critically ill adults: results of a double-blind, randomized, controlled trial

OBJECTIVES

The aims of this study were to evaluate the safety and efficacy of magnesium replacement therapy and to determine its effect on potassium retention in hypokalemic, critically ill patients.

DESIGN

A prospective, double-blind, randomized, placebo-controlled trial.

SETTING

A surgical intensive care unit (ICU).

PATIENTS

A total of 32 adult surgical ICU patients were admitted to the study on the basis of documented hypokalemia (potassium of < 3.5 mmol/L) within the 24-hr period before entering the study. Patients were randomized to receive either placebo (n = 15) or magnesium sulfate (n = 17). One patient from each group was excluded from the study due to failure to complete the full series of doses.

INTERVENTIONS

Patients received a "test dose" of either magnesium sulfate (2 g, 8 mmol) or placebo (5% dextrose in water) infused over 30 mins every 6 hrs for eight doses. The next schedule test dose was held if hypermagnesemia (magnesium of > 2.8 mg/dL [> 1.15 mmol/L]) was documented at any time during the study. Routine replacements of potassium and magnesium continued during the duration of the study, when clinically indicated, for serum potassium concentrations of 3.5 mmol/L or serum magnesium concentrations of < 1.8 mg/dL (< 0.74 mmol/L).

MEASUREMENTS AND MAIN RESULTS

Age, weight, and Acute Physiology and Chronic Health Evaluation II scores were recorded on entry into the study. Just before administration of each test dose, blood was drawn for magnesium and potassium, bicarbonate, pH, and glucose determinations, and an aliquot of the preceding 6 hrs urine collection was sent for magnesium and potassium determinations. Serum calcium, phosphate, urea nitrogen, and creatinine concentrations were measured daily. The amounts of magnesium and potassium administered via parenteral nutrition, tube feeding, and replacement infusions were calculated for each 6-hr interval. The amounts of magnesium and potassium excreted in the urine were similarly assessed. The groups showed no differences with regard to age, weight, Acute Physiology and Chronic Health Evaluation II scores, or initial serum magnesium concentration. Initial potassium, bicarbonate, pH, calcium, phosphate, glucose, blood urea nitrogen, and creatinine values were not different between groups. Patients receiving magnesium sulfate showed a statistically significant increase in serum magnesium concentration at 6 hrs when compared with placebo, as well as with itself at time 0 (p < .0001), a difference maintained throughout the study. Compared with the placebo group, the total amount of elemental magnesium administered was significantly greater in the treatment group (1603 +/- 124 vs. 752 +/- 215 mg [65.7 +/- 5.8 vs. 30.8 +/- 8.8 mmol], p < .0001), as was urine magnesium excretion (1000 +/- 156 vs. 541 +/- 68 mg [41.0 +/- 6.4 vs. 22.2 +/- 2.8 mmol] p < .0001). However, the net magnesium balance (total magnesium in - total urine magnesium) was significantly more positive in the treatment group (612 +/- 180 vs. 216 +/- 217 mg [25.1 +/- 7.4 vs. 8.9 +/- 8.9 mmol], p < .005). The treatment and control groups had the same serum potassium concentrations and did not receive different amounts of potassium (245 +/- 39 vs. 344 +/- 45 mmol, respectively, p = .06), although the treatment group required less potassium replacement/6 hrs by 30 hrs compared with itself at time 0 (p < .05). Despite the same serum potassium values, the net potassium balance for 48 hrs was positive in the treatment group (+ 72 +/- 32 mmol) and negative in the control group (-74 +/- 95 mmol, p < .05). There were no complications associated with the magnesium sulfate administration.

CONCLUSIONS

Magnesium sulfate administered according to the above regimen safety and significantly increases the circulating magnesium concentration. Despite greater urine magnesium losses in the treatment group, this group exhibited significantly better magnesium retention.

Differential regulation of circulating Mg2+ in the rat by beta 1- and beta 2-adrenergic receptor stimulation

Extracellular Mg2+ homeostasis was studied in vivo in the anesthetized rat. Animals were infused with isoproterenol (ISO) for 10 minutes, and serum Mg2+ was measured after the infusion and then 10 and 20 minutes later. A dose-dependent increase in circulating Mg2+ was observed in animals infused with ISO at a rate of 0.1 microgram.kg-1.min-1 or higher. The time course of the effect demonstrated that circulating Mg2+ continued to increase 20 minutes after the end of the ISO infusion. A predicted maximal increase in serum Mg2+ concentration of 19.3% was derived with a predicted EC50 of 0.08 microgram.kg-1.min-1. The maximal percent increase corresponded to a net increase of 6.7 mumol/300 g body wt. Because infusion of ISO resulted in changes in hemodynamic parameters, most notably a drop in blood pressure, a group of animals was infused with nitroprusside to mimic the hypotensive response via a nonadrenergic mechanism. Under these conditions, there was a transient increase in circulating Mg2+ that was largely inhibited by propranolol, indicating that hypotension per se was not responsible for the mobilization of Mg2+. Infusion of salbutamol, but not prenalterol, also induced an increase in circulating Mg2+. Pretreatment with butoxamine, ICI-118551, or propranolol prevented the ISO-induced increase in serum Mg2+. Pretreatment with atenolol minimally affected the ISO-induced changes in circulating Mg2+. Pretreatment with CGP-20271A actually enhanced the ISO-induced increase in circulating Mg2+. This evidence demonstrates the existence of a pool of Mg2+ that is mobilized into the circulation in response to selective beta 2-adrenergic stimulation.

Atrial fibrillation and flutter: maintaining stability of sinus rhythm versus ventricular rate control

Two major treatment strategies have emerged for managing atrial fibrillation: maintaining sinus rhythm by chronic administration of suppressive antiarrhythmic agents versus controlling the ventricular rate and chronic anticoagulation. Potential benefits of maintenance of sinus rhythm include improvement of the hemodynamic profile of the patient, a decreased risk of cerebrovascular accidents, reduced symptoms, and, if atrial fibrillation is successfully suppressed, possible elimination of the need for the chronic anticoagulation. When selecting long-term antiarrhythmic drug therapy for suppression of atrial fibrillation, it should be recalled that at least 50% of patients have a recurrence of the arrhythmia within the first year and the majority of other patients have a recurrence within the next 3 to 5 years. In addition, the risk of proarrhythmia and sudden cardiac death must be considered; this has stimulated interest in nonpharmacologic approaches to maintaining sinus rhythm. Large multicenter randomized trials are now under way to compare the benefits and risks of maintaining sinus rhythm versus controlling the ventricular rate and chronically anticoagulating patients in atrial fibrillation. Important endpoints of these trials include mortality, functional capacity, and quality of life.

ISIS 4: clinical controversy regarding magnesium infusion, thrombolytic therapy, and acute myocardial infarction

Magnesium (Mg) infusions over 24 hours were given to patients with suspected acute myocardial infarction (AMI) at least 2 hours after thrombolysis. Patients showed no benefit and even some increased risk in contrast to reduction in mortality obtained by Mg therapy in smaller trials. Results of all of the studies were pooled and statistically analyzed, according to a fixed-effects model that is inappropriate for studies of different protocols. The panel concluded that further study of Mg in AMI is not needed. This conclusion has been questioned.

Magnesium deficiency modulates hepatic lipogenesis and apolipoprotein gene expression in the rat

The present study was performed to determine the effects of magnesium (Mg) deficiency upon plasma lipoproteins and hepatic apolipoprotein gene expression in the rat. The most obvious effect of Mg-deficiency on plasma lipids is a marked increase in post-prandial triacylglycerol concentration. This increased triglyceridemia persists in fasted rats. Density gradient ultracentrifugation analysis revealed marked alterations in the distribution of plasma lipoproteins in Mg-deficient rats. An increase in triacylglycerol-rich lipoproteins (TGRLP) was associated with a significant increase in plasma apolipoprotein B (apo B) concentration and was accompanied by selective accumulation of apo B-48. A decrease in high-density lipoproteins (HDL) was accompanied by a corresponding decrease in plasma apo E concentration and a concordant decrease in hepatic apo E mRNA abundance and biosynthesis. Hepatic apo B-100 synthesis was reduced by over 75% in Mg-deficient animals despite an increase in hepatic apo B mRNA abundance. However, this change in hepatic apo B gene expression was not associated with alterations in posttranscriptional apo B mRNA editing. These changes in apolipoprotein gene expression were associated with increased hepatic lipogenesis, despite the observation that net triacylglycerol secretion rates were not different between Mg-deficient and control animals. Taken together, the data demonstrate a complex pattern of alterations in hepatic lipid metabolism and apolipoprotein gene expression in the Mg-deficient rat and suggest a defect in the catabolism rather than secretion of TGLRP as the major factor underlying the altered plasma lipoprotein profile.

Relationship between erythrocyte magnesium, plasma electrolytes and cortisol, and intensity of symptoms in major depressed patients

53 male and female drug-free major depressed patients were separated into three groups according to the severity of the depression. In the entire regrouped population, plasma and erythrocyte magnesium (Mg) were shown to increase as compared with 48 healthy controls, confirming our previous studies. The middle and highly depressed patients had higher erythrocyte and also plasma Mg levels than either lowly depressed patients or controls. Only, a few differences were noticed in plasma sodium, potassium and calcium (Ca) in the three groups of patients, except for ultrafiltrable plasma Ca, measured for the first time in affective disorders. Thus, erythrocyte and also plasma Mg are shown to be associated with the intensity of the depression. As blood hypomagnaesemia is often related to hyperexcitability, further investigations are actually in process to shown whether hypermagnesaemia might be, in contrast, associated with psychomotor retardation as observed in many depressed patients.

Aluminum phosphide poisoning--a review

Aluminum phosphide poisoning is common in the rural belt of Northern India. The release of cytotoxic phosphine gas primarily affects the heart, lungs, gastrointestinal tract and kidneys, although all organs can be involved. The cellular site of action of phosphine requires further definition. Diagnosis is made by clinical suspicion, silver nitrate test and biochemical examination of the gastric aspirate and viscera. Treatment consists of early gastric lavage, vasopressors and supportive care. Specific therapy with intravenous magnesium sulphate is recommended.

Magnesium in acute myocardial infarction

Clinical studies on the use of magnesium in acute myocardial infarction have yielded contradictory results. While the exact reasons for these discrepancies are unclear, it appears that the timing of magnesium administration is crucial to the success or failure of therapy. Although some studies have shown a significant reduction in the odds of death with this agent, the exact reasons underlying this possible benefit are not yet fully understood. A reduction in arrhythmias, inhibition of thrombus generation, changes in coronary and peripheral hemodynamics, and the limitation of ischemic damage and reperfusion injury have been inferred as possible mechanisms. IV magnesium is inexpensive and easy to administer, and has minimal side effects. While further research on magnesium therapy in ischemic states is warranted, the early use of IV magnesium should be considered in selected patients with suspected acute myocardial infarction.

Hypertension: are beta-blockers and diuretics appropriate first-line therapies?

OBJECTIVE

To review the existing data on the use of diuretics or beta-blockers as first-line therapy for the treatment of mild to moderate hypertension, and to examine the issues surrounding the impact of these classes as well as the angiotensin-converting enzyme (ACE) inhibitors, calcium-channel blockers (CCBs), alpha-blockers, and alpha-beta-blockers on cardiovascular risk factors and cardiovascular morbidity and mortality.

DATA SOURCES

A MEDLINE search of applicable articles on antihypertensive therapies and their impact on morbidity and mortality. In addition, a MEDLINE search of relevant articles regarding cardiovascular risk factors and the influence of the various antihypertensive therapies on these parameters.

DATA SYNTHESIS

The literature was evaluated with regard to outcome. Trials examining the impact of antihypertensive pharmacotherapy, primarily with diuretics and beta-blockers, have shown them to decrease the incidence of stroke by 33-50 percent. However, their effect on coronary heart disease has been disappointing, showing only a 14 +/- 5 (mean +/- SD) percent decrease. Examination of numerous clinical trials assessing the impact of the various antihypertensive therapies on cardiovascular risk factors, including blood pressure, plasma lipids, diabetic control/insulin sensitivity, and left ventricular hypertrophy was done. The classes included beta-blockers, diuretics, alpha-blockers, ACE inhibitors, and CCBs; the results show a diversity of effect. Diuretics and beta-blockers tend to worsen cardiovascular risk status, whereas the alpha-blockers, ACE inhibitors, and CCBs all show a beneficial effect.

CONCLUSIONS

Diuretics and beta-blockers can effectively reduce cerebrovascular morbidity and mortality, but have a limited effect on reducing cardiovascular disease, especially myocardial infarction. This may be explained, at least in part, by the negative, or lack of positive, effect on individual patients' overall cardiovascular risk status.