Prevention and elimination of heart arrhythmias by adaptation to intermittent high altitude hypoxia

The incidence and risk factors of perioperative cardiac complications in noncardiac major surgery in high-altitude areas: A prospective trial in Tibet autonomous region, China

Background

The risk of perioperative cardiac complications (PCCs) in patients living in high-altitude areas may increase with more adverse clinical outcomes due to the special geographical environment, which has not yet been studied. We aimed to determine the incidence and analyze risk factors for PCCs in adult patients undergoing major noncardiac surgery in the Tibet Autonomous Region.

Methods

This prospective cohort study enrolled resident patients from high-altitude areas receiving major noncardiac surgery in Tibet Autonomous Region People's Hospital in China. Perioperative clinical data were collected, and the patients were followed up until 30 days after surgery. The primary outcome was PCCs during the operation and within 30 days after the surgery. Logistic regression was used to build the prediction models for PCCs. A receiver operating characteristic (ROC) curve was used to evaluate the discrimination. A prognostic nomogram was constructed to generate a numerical probability of PCCs for patients undergoing noncardiac surgery in high-altitude areas.

Results

Among the 196 patients living in high-altitude areas involved in this study, 33 (16.8%) suffered PCCs perioperatively and within 30 days after surgery. Eight clinical factors were identified in the prediction model, including older age (P = 0.028), extremely high altitude above 4,000 m (P = 0.442), preoperative metabolic equivalent (MET) < 4 (P = 0.153), history of angina within 6 months (P = 0.037), history of great vascular disease (P = 0.073), increased preoperative high sensitivity C-reactive protein (hs-CRP) (P = 0.072), intraoperative hypoxemia (P = 0.025) and operation time >3 h (P = 0.043). The area under the curve (AUC) was 0.766 (95% confidence interval: 0.785–0.697). The score calculated from the prognostic nomogram predicted the risk of PCCs in high-altitude areas.

Conclusion

The incidence of PCCs in resident patients living in high-altitude areas who underwent noncardiac surgery was high, and the risk factors included older age, high altitude above 4,000 m, preoperative MET < 4, history of angina within 6 months, history of great vascular disease, increased preoperative hs-CRP, intraoperative hypoxemia, and operation time >3 h. The prognostic nomogram of this study could help to assess the PCCs for patients in high-attitude areas undergoing noncardiac surgery.

Clinical Trial Registration

ClinicalTrials.gov ID: NCT04819698.

The effect of adaptation to hypoxia on cardiac tolerance to ischemia/reperfusion

The acute myocardial infarction (AMI) and sudden cardiac death (SCD), both associated with acute cardiac ischemia, are one of the leading causes of adult death in economically developed countries. The development of new approaches for the treatment and prevention of AMI and SCD remains the highest priority for medicine. A study on the cardiovascular effects of chronic hypoxia (CH) may contribute to the development of these methods. Chronic hypoxia exerts both positive and adverse effects. The positive effects are the infarct-reducing, vasoprotective, and antiarrhythmic effects, which can lead to the improvement of cardiac contractility in reperfusion. The adverse effects are pulmonary hypertension and right ventricular hypertrophy. This review presents a comprehensive overview of how CH enhances cardiac tolerance to ischemia/reperfusion. It is an in-depth analysis of the published data on the underlying mechanisms, which can lead to future development of the cardioprotective effect of CH. A better understanding of the CH-activated protective signaling pathways may contribute to new therapeutic approaches in an increase of cardiac tolerance to ischemia/reperfusion.

Intermittent Hypoxia Induces Autophagy to Protect Cardiomyocytes From Endoplasmic Reticulum Stress and Apoptosis

Intermittent hypoxia (IH), characterized as cyclic episodes of short-period hypoxia followed by normoxia, occurs in many physiological and pathophysiological conditions such as pregnancy, athlete, obstructive sleep apnea, and asthma. Hypoxia can induce autophagy, which is activated in response to protein aggregates, in the proteotoxic forms of cardiac diseases. Previous studies suggested that autophagy can protect cells by avoiding accumulation of misfolded proteins, which can be generated in response to ischemia/reperfusion (I/R) injury. The objective of the present study was to determine whether IH-induced autophagy can attenuate endoplasmic reticulum (ER) stress and cell death. In this study, H9c2 cell line, rat primary cultured cardiomyocytes, and C57BL/6 male mice underwent IH with an oscillating O₂ concentration between 4 and 20% every 30 min for 1-4 days in an incubator. The levels of LC3, an autophagy indicator protein and CHOP and GRP78 (ER stress-related proteins) were measured by Western blotting analyses. Our data demonstrated that the autophagy-related proteins were upregulated in days 1-3, while the ER stress-related proteins were downregulated on the second day after IH. Treatment with H₂O₂ (100 μM) for 24 h caused ER stress and increased the level of ER stress-related proteins, and these effects were abolished by pre-treatment with IH condition. In response to the autophagy inhibitor, the level of ER stress-related proteins was upregulated again. Taken together, our data suggested that IH could increase myocardial autophagy as an adaptive response to prevent the ER stress and apoptosis.

Cardioprotection by intermittent hypoxia conditioning: evidence, mechanisms, and therapeutic potential

The calibrated application of limited-duration, cyclic, moderately intense hypoxia-reoxygenation increases cardiac resistance to ischemia-reperfusion stress. These intermittent hypoxic conditioning (IHC) programs consistently produce striking reductions in myocardial infarction and ventricular tachyarrhythmias after coronary artery occlusion and reperfusion and, in many cases, improve contractile function and coronary blood flow. These IHC protocols are fundamentally different from those used to simulate sleep apnea, a recognized cardiovascular risk factor. In clinical studies, IHC improved exercise capacity and decreased arrhythmias in patients with coronary artery or pulmonary disease and produced robust, persistent, antihypertensive effects in patients with essential hypertension. The protection afforded by IHC develops gradually and depends on β-adrenergic, δ-opioidergic, and reactive oxygen-nitrogen signaling pathways that use protein kinases and adaptive transcription factors. In summary, adaptation to intermittent hypoxia offers a practical, largely unrecognized means of protecting myocardium from impending ischemia. The myocardial and perhaps broader systemic protection provided by IHC clearly merits further evaluation as a discrete intervention and as a potential complement to conventional pharmaceutical and surgical interventions.

Involvement of Autonomic Nervous System in Antiarrhythmic Effect of Intermittent Hypobaric Hypoxia

We studied the involvement of the autonomic nervous system in the antiarrhythmic effect of intermittent hypobaric hypoxia modeled by daily placing the rats into an altitude chamber at 405 mm Hg (5000 m above sea level). The antiarrhythmic effect of hypoxia was observed on the model of acute coronary occlusion/reperfusion in vivo, but not during simulation of total ischemia/reperfusion of the isolated myocardium. Intravenous injection of ganglionic blocker hexamethonium (30 mg/kg) 15 min prior to in vivo coronary occlusion modeling abolished the antiarrhythmic effect of intermittent hypobaric hypoxia, which suggests that this effect is mediated via activation of the autonomic nervous system.

Pharmacological models and approaches for pathophysiological conditions associated with hypoxia and oxidative stress

Hypoxia is the failure of oxygenation at the tissue level, where the reduced oxygen delivered is not enough to satisfy tissue demands. Metabolic depression is the physiological adaptation associated with reduced oxygen consumption, which evidently does not cause any harm to organs that are exposed to acute and short hypoxic insults. Oxidative stress (OS) refers to the imbalance between the generation of reactive oxygen species (ROS) and the ability of endogenous antioxidant systems to scavenge ROS, where ROS overwhelms the antioxidant capacity. Oxidative stress plays a crucial role in the pathogenesis of diseases related to hypoxia during intrauterine development and postnatal life. Thus, excessive ROS are implicated in the irreversible damage to cell membranes, DNA, and other cellular structures by oxidizing lipids, proteins, and nucleic acids. Here, we describe several pathophysiological conditions and in vivo and ex vivo models developed for the study of hypoxic and oxidative stress injury. We reviewed existing literature on the responses to hypoxia and oxidative stress of the cardiovascular, renal, reproductive, and central nervous systems, and discussed paradigms of chronic and intermittent hypobaric hypoxia. This systematic review is a critical analysis of the advantages in the application of some experimental strategies and their contributions leading to novel pharmacological therapies.

Current insights into the molecular mechanisms of hypoxic pre- and postconditioning using hypobaric hypoxia

Exposure of organisms to repetitive mild hypoxia results in development of brain hypoxic/ischemic tolerance and cross-tolerance to injurious factors of a psycho-emotional nature. Such preconditioning by mild hypobaric hypoxia functions as a “warning” signal which prepares an organism, and in particular the brain, to subsequent more harmful conditions. The endogenous defense processes which are mobilized by hypoxic preconditioning and result in development of brain tolerance are based on evolutionarily acquired gene-determined mechanisms of adaptation and neuroprotection. They involve an activation of intracellular cascades including kinases, transcription factors and changes in expression of multiple regulatory proteins in susceptible areas of the brain. On the other hand they lead to multilevel modifications of the hypothalamic-pituitary-adrenal endocrine axis regulating various functions in the organism. All these components are engaged sequentially in the initiation, induction and expression of hypoxia-induced tolerance. A special role belongs to the epigenetic regulation of gene expression, in particular of histone acetylation leading to changes in chromatin structure which ensure access of pro-adaptive transcription factors activated by preconditioning to the promoters of target genes. Mechanisms of another, relatively novel, neuroprotective phenomenon termed hypoxic postconditioning (an application of mild hypoxic episodes after severe insults) are still largely unknown but according to recent data they involve apoptosis-related proteins, hypoxia-inducible factor and neurotrophins. The fundamental data accumulated to date and discussed in this review open new avenues for elaboration of the effective therapeutic applications of hypoxic pre- and postconditioning.

Heart rate and blood pressure responses during hypoxic cycles of a 3-week intermittent hypoxia breathing program in patients at risk for or with mild COPD

The aim of this study was to provide information on heart rate and blood pressure responses during a 3-week intermittent hypoxia breathing program in COPD patients. Sixteen participants with COPD symptoms were randomly assigned to a hypoxia or control group and completed a 3-week intermittent hypoxia breathing program (five sessions per week, each consisting of three to five breathing cycles, each cycle lasting 3–5 minutes with 3-minute breaks between cycles). During the breathing cycles, the hypoxia group received hypoxic air (inspired fraction of oxygen 15%–12%), whereas the control group received normal air (sham hypoxia). During the breaks, all participants breathed normoxic room air. Arterial oxygen saturation, systolic and diastolic blood pressure, and heart rate were measured during the normoxic and hypoxic/sham hypoxic periods. For each breathing cycle, changes from normoxia to hypoxia/sham hypoxia were calculated, and changes were averaged for each of the 15 sessions and for each week. Changes in arterial oxygen saturation were significantly different between groups in the course of the 3 weeks (two-way analysis of variance for repeated measures), with post hoc differences in weeks 1, 2, and 3. During the course of the intermittent hypoxia application, no between-group differences were detected for blood pressure or rate pressure product values. Changes in heart rate were significantly different between groups in the course of the 3 weeks (two-way analysis of variance for repeated measures), with post hoc differences only in week 3. Averages over all 15 sessions were significantly higher in the hypoxia group for heart rate and rate pressure product, and tended to be increased for systolic blood pressure. The applied intermittent hypoxia breathing program resulted in specific and moderate heart rate and blood pressure responses, and did not provoke a progressive increase in blood pressure during the hypoxic cycles in the course of the application.

Hypoxic Conditioning as a New Therapeutic Modality

Preconditioning refers to a procedure by which a single noxious stimulus below the threshold of damage is applied to the tissue in order to increase resistance to the same or even different noxious stimuli given above the threshold of damage. Hypoxic preconditioning relies on complex and active defenses that organisms have developed to counter the adverse consequences of oxygen deprivation. The protection it confers against ischemic attack for instance as well as the underlying biological mechanisms have been extensively investigated in animal models. Based on these data, hypoxic conditioning (consisting in recurrent exposure to hypoxia) has been suggested a potential non-pharmacological therapeutic intervention to enhance some physiological functions in individuals in whom acute or chronic pathological events are anticipated or existing. In addition to healthy subjects, some benefits have been reported in patients with cardiovascular and pulmonary diseases as well as in overweight and obese individuals. Hypoxic conditioning consisting in sessions of intermittent exposure to moderate hypoxia repeated over several weeks may induce hematological, vascular, metabolic, and neurological effects. This review addresses the existing evidence regarding the use of hypoxic conditioning as a potential therapeutic modality, and emphasizes on many remaining issues to clarify and future researches to be performed in the field.

Combined exposure to hypercapnia and hypoxia provides its maximum neuroprotective effect during focal ischemic injury in the brain

BACKGROUND

In the present research, we compared the neuroprotective efficiency of combined and isolated exposure to hypoxia and hypercapnia preceding focal cerebral ischemic injury in rats. The study was conducted to verify the hypothesis of a possible increase in normobaric hypoxia (NbH; 90 mm Hg) efficiency when combined with permissive hypercapnia (PH; 50 mm Hg).

METHODS

The rats from the test groups were subjected to a 15-fold exposure to NbH (90 mm Hg) and/or PH (50 mm Hg). After the 15th exposure, cerebral ischemic injury was induced by photochemical thrombosis. Seventy-two hours later, neurologic deficit was determined on the Neurological Severity Score scale and by the rotarod test, and the volume of cerebral infarction was measured after focal photochemical thrombosis.

RESULTS

The neurologic deficit decreased most efficiently in rats that underwent PH and hypercapnic hypoxia (HH) exposure, whereas NbH had no impact on the neurologic status of the animals. On the contrary, motor coordination disturbances were minimal during exposure to hypoxia and HH. All respiratory interventions reduced the cerebral ischemic infarction volume in rats. The smallest infarction volumes were registered in the area of photochemical thrombosis in rats from the hypercapnic-hypoxic impact group, whereas exposure to NbH or PH did not show any cross difference.

CONCLUSIONS

The impact of PH has greater neuroprotective potential compared with NbH. Thus, we can assume that hypercapnia is a predominant factor in providing neuroprotection in combination with hypoxia.

The polymorphic and contradictory aspects of intermittent hypoxia

Intermittent hypoxia (IH) has been extensively studied during the last decade, primarily as a surrogate model of sleep apnea. However, IH is a much more pervasive phenomenon in human disease, is viewed as a potential therapeutic approach, and has also been used in other disciplines, such as in competitive sports. In this context, adverse outcomes involving cardiovascular, cognitive, metabolic, and cancer problems have emerged in obstructive sleep apnea-based studies, whereas beneficial effects of IH have also been identified. Those a priori contradictory findings may not be as contradictory as initially thought. Indeed, the opposite outcomes triggered by IH can be explained by the specific characteristics of the large diversity of IH patterns applied in each study. The balance between benefits and injury appears to primarily depend on the ability of the organism to respond and activate adaptive mechanisms to IH. In this context, the adaptive or maladaptive responses can be generally predicted by the frequency, severity, and duration of IH. However, the presence of underlying conditions such as hypertension or obesity, as well as age, sex, or genotypic variance, may be important factors tilting the balance between an appropriate homeostatic response and decompensation. Here, the two possible facets of IH as derived from human and experimental animal settings will be reviewed.

Comparative analysis of early and delayed cardioprotective and antiarrhythmic efficacy of hypoxic preconditioning

Hypoxic preconditioning produces an infarct-limiting effect both in the early and delayed periods. The increase in heart resistance to ischemia-repefusion was more pronounced after early preconditioning. Hypoxic preconditioning did not change heart resistance to the arrhythmogenic effect of coronary occlusion and reperfusion.

Effects of a single bout of interval hypoxia on cardiorespiratory control in patients with type 1 diabetes

Hypoxemia is common in diabetes, and reflex responses to hypoxia are blunted. These abnormalities could lead to cardiovascular/renal complications. Interval hypoxia (IH) (5-6 short periods of hypoxia each day over 1-3 weeks) was successfully used to improve the adaptation to hypoxia in patients with chronic obstructive pulmonary disease. We tested whether IH over 1 day could initiate a long-lasting response potentially leading to better adaptation to hypoxia. In 15 patients with type 1 diabetes, we measured hypoxic and hypercapnic ventilatory responses (HCVRs), ventilatory recruitment threshold (VRT-CO2), baroreflex sensitivity (BRS), blood pressure, and blood lactate before and after 0, 3, and 6 h of a 1-h single bout of IH. All measurements were repeated on a placebo day (single-blind protocol, randomized sequence). After IH (immediately and after 3 h), hypoxic and HCVR increased, whereas the VRT-CO2 dropped. No such changes were observed on the placebo day. Systolic and diastolic blood pressure increased, whereas blood lactate decreased after IH. Despite exposure to hypoxia, BRS remained unchanged. Repeated exposures to hypoxia over 1 day induced an initial adaptation to hypoxia, with improvement in respiratory reflexes. Prolonging the exposure to IH (>2 weeks) in type 1 diabetic patients will be a matter for further studies.

Normobaric, intermittent hypoxia conditioning is cardio- and vasoprotective in rats

Favorable versus detrimental cardiovascular responses to intermittent hypoxia conditioning (IHC) are heavily dependent on experimental or pathological conditions, including the duration, frequency and intensity of the hypoxia exposures. Recently, we demonstrated that a program of moderate, normobaric IHC (FIO2 9.5-10% for 5-10 min/cycle, with intervening 4 min normoxia, 5-8 cycles/day for 20 days) in dogs afforded robust cardioprotection against infarction and arrhythmias induced by coronary artery occlusion-reperfusion, but this protection has not been verified in other species. Accordingly, in this investigation cardio- as well as vasoprotection were examined in male Wistar rats completing the normobaric IHC program or a sham program in which the rats continuously breathed atmospheric air. Myocardial ischemia and reperfusion (IR) was imposed by occlusion and reperfusion of the left anterior descending coronary artery in in situ experiments and by subjecting isolated, perfused hearts to global ischemia-reperfusion. Cardiac arrhythmias and myocardial infarct size were quantified in in situ experiments. Endothelial function was evaluated from the relaxation to acetylcholine of norepinephrine-precontracted aortic rings taken from in situ IR experiments, and from the increase in coronary flow produced by acetylcholine in isolated hearts. IHC sharply reduced cardiac arrhythmias during ischemia and decreased infarct size by 43% following IR. Endothelial dysfunction in aorta was marked after IR in sham rats, but not significant in IHC rats. Similar findings were found for the coronary circulations of isolated hearts. These findings support the hypothesis that moderate, normobaric IHC is cardio- and vasoprotective in a rat model of IR.

Tolerance to acute hypoxia maximally increases in case of joint effect of normobaric hypoxia and permissive hypercapnia in rats

INTRODUCTION

We studied the comparative efficacy of independent and combined effects of normobaric hypoxia (90mmHg) and permissive hypercapnia (50mmHg) in increasing the tolerance of rats to acute hypobaric hypoxia.

METHODS

We determined the time to loss of pose and life duration as a measure to assess the degree of tolerance of animals to hypobaric hypoxia by exposing them to an altitude of 11,500m (barometric=180mmHg).

RESULTS

Exposure to hypercapnic hypoxia increased the tolerance to acute hypobaric hypoxia compared to exposure to normobaric hypoxia or permissive hypercapnia alone.

DISCUSSION

The positive effects of hypercapnia and hypercapnic hypoxia occurred after one exposure, and increasing the number of exposures proportionally increased the tolerance to acute hypobaric hypoxia. The effect of permissive hypercapnia on increasing the tolerance to acute hypobaric hypoxia was found to be significantly greater than that of exposure to normobaric hypoxia. Therefore, we propose that hypercapnia is the dominant factor in increasing tolerance to acute hypobaric hypoxia.

CONCLUSION

Tolerance to acute hypoxia maximally increases in case of joint effect of normobaric hypoxia and permissive hypercapnia.

Role of endogenous opioid peptides in the infarct size-limiting effect of adaptation to chronic continuous hypoxia

AIMS

The objective of this study was to examine the involvement of endogenous opioid peptides and opioid receptor (OR) subtypes in the cardioprotective effect of adaptation to chronic hypoxia in rats.

MAIN METHODS

Rats were exposed to continuous normobaric hypoxia (CNH; 12% oxygen) for 3 weeks. Myocardial ischemia was induced by 20-min coronary artery occlusion followed by 3-h reperfusion in anesthetized open-chest animals. Various OR antagonists were administered to rats prior to ischemia. The size of myocardial infarction and the incidence of ischemic ventricular arrhythmias were assessed. Myocardial and plasma concentrations of opioid peptides (met-enkephalin, β-endorphin, and endomorphins) were determined.

KEY FINDINGS

Adaptation to CNH significantly increased myocardial and plasma concentrations of opioids, potentiated their further elevation by ischemia/reperfusion, and reduced myocardial infarct size, but it did not affect the incidence of ischemic arrhythmias. The infarct size-limiting effect of CNH was abolished by OR antagonists naltrexone (non-selective), naloxone methiodide (non-selective peripherally acting), TIPP[ψ] (δ-OR), naltriben (δ2-OR), or CTAP (μ-OR), while BNTX (δ1-OR) and nor-binaltorphimine (κ-OR) had no effect.

SIGNIFICANCE

The results suggest that the infarct size-limiting effect afforded by adaptation to CNH is mediated by activation of peripheral δ2- and μ-ORs by elevated levels of endogenous opioid peptides.

Intermittent hypobaric hypoxia induces neuroprotection in kainate-induced oxidative stress in rats

Severe hypoxia induces oxidative stress, which can lead to brain injury. In this study, we wanted to determine whether intermittent hypobaric hypoxia induces oxidative stress in the brain. In adult rats exposed to 380 mmHg in a hypobaric chamber for 3 h/day for 6 days, we determined the levels of malondialdehyde and nitric oxide derivatives in the brain, which indicated that there was no oxidative stress. The levels of N-acetylaspartate indicated that there was no neuronal loss or mitochondrial dysfunction and finally because apoptotic proteins such as caspase-3 and nuclear factor-kappa B (NF-κB) were not activated, apoptosis was probably not induced. The increase in the expression of erythropoietin (EPO) in the brain of rats exposed to hypoxia confirms the efficacy of the method used to induce hypoxia in the brain. Because EPO have antioxidant effects on the brain, the results suggest that intermittent hypoxia can increase the antioxidant capacity of the brain. This effect of intermittent hypoxia was studied using the systemic administration of kainate, as a model of brain oxidative stress. Kainate treatment induces oxidative stress in the brain, which is measured by an increase in lipid peroxidation and nitric oxide. Furthermore, in rats treated with kainate, both caspase-3 and NF-κB activity increased. However, in rats previously exposed to intermittent hypobaric hypoxia, 3 h per day for 6 days, the effect of kainate treatment resulted in the reduction of both oxidative stress and apoptotic activity. This study demonstrates that intermittent hypobaric hypoxia can increase brain antioxidant capacity in rats and induces neuroprotection in kainate-induced oxidative injury.

Intermittent hypobaric hypoxia applicability in myocardial infarction prevention and recovery

Intermittent hypobaric hypoxia (IHH) has been the focus of important research in cardioprotection, and it has been associated with several mechanisms. Intermittent hypobaric hypoxia inhibits prolyl hydroxylases (PHD) activity, increasing the stabilization of hypoxia-inducible factor-1 (HIF-1) and activating crucial adaptative genes. It has been hence suggested that IHH might be a simple intervention, which may offer a thoughtful benefits to patients with acute myocardial infarction and no complications. Nevertheless, several doubts exist as to whether IHH is a really safe technique, with little to no complications in post-myocardial infarction patients. Intermittent hypobaric hypoxia might produce instead unfavourable changes such as impairment of vascular hemodynamics and hypertensive response, increased risk of hemoconcentration and thrombosis, cardiac rhythm perturbations, coronary artery disease and heart failure, insulin resistance, steatohepatitis and even high-altitude pulmonary oedema in susceptible or nonacclimatized patients. Although intermittent and chronic exposures seem effective in cardioprotection, IHH safety issues have been mostly overlooked, so that assorted concerns should be raised about the opportunity to use IHH in the post-myocardial infarction period. Several IHH protocols used in some studies were also aggressive, which would hamper their widespread introduction within the clinical practice. As such, further research is needed before IHH can be widely advocated in myocardial infarction prevention and recovery.

Mitochondrial energy metabolism plays a critical role in the cardioprotection afforded by intermittent hypobaric hypoxia

Intermittent hypobaric hypoxia (IHH) is an effective protective strategy against myocardial ischaemia-reperfusion (I/R) injury, but the precise mechanisms are far from clear. To understand the overall effects of IHH on the myocardial proteins during I/R, we analysed functional performance and the protein expression profile in isolated hearts from normoxic rats and from rats adapted to IHH (5000 m, 4 h day(-1), 4 weeks) following I/R injury (30 min/45 min). Intermittent hypobaric hypoxia significantly improved the postischaemic recovery of left ventricular function compared with the recovery in time-matched normoxic control hearts. Two-dimensional electrophoresis with matrix-assisted laser desorption/ionization and time-of-flight mass spectrometric analysis was then used to assess protein alterations in left ventricles from normoxic and IHH groups, with or without I/R. The expressions of 16 proteins changed by over fivefold; nine of these proteins are involved in energy metabolism. Immunoblot and real-time PCR analysis confirmed the IHH-increased expressions of the ATP synthase subunit β, mitochondrial aldehyde dehydrogenase and heat shock protein 27 in left ventricles. Furthermore, IHH significantly attenuated the reduction of myocardial ATP content, mitochondrial ATP synthase activity, membrane potential and respiratory control ratios due to I/R. In addition, inhibition of mitochondrial ATP synthase by oligomycin (1 μmol l(-1)) abolished the IHH-induced improvements in three parameters: postischaemic recovery of left ventricular function, mitochondrial membrane potential and respiratory control ratios. These results suggest that an improvement in mitochondrial energy metabolism makes an important contribution to the cardioprotection afforded by IHH against postischaemic myocardial dysfunction.

Intermittent hypobaric hypoxia improves postischemic recovery of myocardial contractile function via redox signaling during early reperfusion

Intermittent hypobaric hypoxia (IHH) protects hearts against ischemia-reperfusion (I/R) injury, but the underlying mechanisms are far from clear. ROS are paradoxically regarded as a major cause of myocardial I/R injury and a trigger of cardioprotection. In the present study, we investigated whether the ROS generated during early reperfusion contribute to IHH-induced cardioprotection. Using isolated perfused rat hearts, we found that IHH significantly improved the postischemic recovery of left ventricular (LV) contractile function with a concurrent reduction of lactate dehydrogenase release and myocardial infarct size (20.5 ± 5.3% in IHH vs. 42.1 ± 3.8% in the normoxic control, P < 0.01) after I/R. Meanwhile, IHH enhanced the production of protein carbonyls and malondialdehyde, respective products of protein oxidation and lipid peroxidation, in the reperfused myocardium and ROS generation in reperfused cardiomyocytes. Such effects were blocked by the mitochondrial ATP-sensitive K(+) channel inhibitor 5-hydroxydecanoate. Moreover, the IHH-improved postischemic LV performance, enhanced phosphorylation of PKB (Akt), PKC-ε, and glycogen synthase kinase-3β, as well as translocation of PKC-ε were not affected by applying H(2)O(2) (20 μmol/l) during early reperfusion but were abolished by the ROS scavengers N-(2-mercaptopropionyl)glycine (MPG) and manganese (III) tetrakis (1-methyl-4-pyridyl)porphyrin. Furthermore, IHH-reduced lactate dehydrogenase release and infarct size were reversed by MPG. Consistently, inhibition of Akt with wortmannin and PKC-ε with εV1-2 abrogated the IHH-improved postischemic LV performance. These findings suggest that IHH-induced cardioprotection depends on elevated ROS production during early reperfusion.

Therapeutic effect of intermittent hypobaric hypoxia on myocardial infarction in rats

Intermittent hypobaric hypoxia (IHH) preconditioning protects the heart against ischemic injuries. However, little is known about the therapeutic effect of IHH on myocardial infarction (MI). The aim of this study was to test whether IHH treatment influences infarct size and cardiac performance after MI. Seven days after sham operation or left anterior descending coronary artery ligation, male Sprague-Dawley rats were randomly exposed to normoxia or one 6-h period each day of IHH (5,000 m) for 14 and 28 days. Echocardiography analysis showed that IHH significantly reduced left ventricular (LV) dilation and improved cardiac performance after 14- or 28-day treatment compared with MI-normoxic groups. The improvement of LV function was further confirmed in isolated perfused MI-IHH hearts. Such protection was associated with attenuated infarct size, myocardial fibrosis, and apoptotic cardiomyocytes. IHH treatment also enhanced coronary flow and phosphorylation of heat shock protein 27 in both sham and MI groups compared with the control groups. In addition, IHH increased the capillary density and vascular endothelial growth factor expression in peri-infarcted zones compared with sham-IHH and MI-normoxic groups. Our data demonstrated for the first time that IHH treatment exerts a therapeutic effect on MI by attenuating progressive myocardial remodeling and improving myocardial contractility. IHH treatment might provide a unique and promising therapeutic approach for ischemic heart diseases.

The exercising heart at altitude

Maximal cardiac output is reduced in severe acute hypoxia but also in chronic hypoxia by mechanisms that remain poorly understood. In theory, the reduction of maximal cardiac output could result from: (1) a regulatory response from the central nervous system, (2) reduction of maximal pumping capacity of the heart due to insufficient coronary oxygen delivery prior to the achievement of the normoxic maximal cardiac output, or (3) reduced central command. In this review, we focus on the effects that acute and chronic hypoxia have on the pumping capacity of the heart, particularly on myocardial contractility and the molecular responses elicited by acute and chronic hypoxia in the cardiac myocytes. Special emphasis is put on the cardioprotective effects of chronic hypoxia.

Calcium/calmodulin-dependent protein kinase II mediates cardioprotection of intermittent hypoxia against ischemic-reperfusion-induced cardiac dysfunction

Intermittent high-altitude (IHA) hypoxia-induced cardioprotection against ischemia-reperfusion (I/R) injury is associated with the preservation of sarcoplasmic reticulum (SR) function. Although Ca(2+)/calmodulin (CaM)-dependent protein kinase II (CaMKII) and phosphatase are known to modulate the function of cardiac SR under physiological conditions, the status of SR CaMKII and phosphatase during I/R in the hearts from IHA hypoxic rats is unknown. In the present study, we determined SR and cytosolic CaMKII activity during preischemia and I/R (30 min/30 min) in perfused hearts from normoxic and IHA hypoxic rats. The left ventricular contractile recovery, SR CaMKII activity as well as phosphorylation of phospholamban at Thr(17), and Ca(2+)/CaM-dependent SR Ca(2+)-uptake activity were depressed in the I/R hearts from normoxic rats, whereas these changes were prevented in the hearts from IHA hypoxic rats. Such beneficial effects of IHA hypoxia were lost by treating the hearts with a specific CaMKII inhibitor, KN-93. I/R also depressed cytosolic CaMKII and SR phosphatase activity, but these alterations remained unchanged in IHA hypoxic group. Furthermore, we found that the autophosphorylation at Thr(287), which confers Ca(2+)/CaM-independent activity, was not altered by I/R in both groups. These findings indicate that preservation of SR CaMKII activity plays an important role in the IHA hypoxia-induced cardioprotection against I/R injury via maintaining SR Ca(2+)-uptake activity.

Role of ATP-sensitive K(+)-channels in antiarrhythmic and cardioprotective action of adaptation to intermittent hypobaric hypoxia

Mature Wistar rats were exposed to intermittent hypobaric hypoxia (5000 m, 6 h/day, 30 sessions). This mode of adaptation enhanced heart tolerance to the arrhythmogenic action of 45-min coronary occlusion, but does not affect the infarction size/risk area ratio. In some series, the rats were exposed to more severe intermittent hypobaric hypoxia (7000 m, 8 h/day, 6 weeks) followed by 20-min coronary occlusion and 3-h reperfusion one day after the last hypoxia session. In this case, adaptation reduced the infarction size/risk area ratio and enhanced cardiac tolerance to the arrhythmogenic effect of reperfusion, but had no effect on the incidence of ventricular arrhythmia during ischemia. We found that the cardioprotective and antiarrhythmic effects of adaptation to an altitude of 7000 m and the antiarrhythmic effect of 5000-m adaptation were mediated via activation of K(ATP) channels.

Intermittent hypoxia increases exercise tolerance in patients at risk for or with mild COPD

The effects of repeated short-term hypoxia on exercise tolerance in patients at risk for, or with mild COPD were investigated. Eighteen patients (10 males, 8 females; 33-72 years) were randomly assigned in a double-blind fashion to receive 15 sessions of intermittent hypoxia (FiO(2): 0.15-0.12) or normoxia within 3 weeks. Three weeks of intermittent hypoxia increased total haemoglobin mass (+4% vs. 0%, p<0.05), total exercise time (+9.7% vs. 0%, p<0.05) and the exercise time to the anaerobic threshold (+13% vs. -7.8%, p<0.05) compared to controls. Changes in the total exercise time were positively related to the changes in total haemoglobin mass (r=0.59, p<0.05) and changes in the time to the anaerobic threshold were positively related to the changes in the lung diffusion capacity for carbon monoxide (r=0.48, p<0.05). Intermittent hypoxia treatment may be a valuable addition to therapy designed to improve exercise tolerance in patients at risk for, or with mild COPD.

Cardiac metabolic adaptations in response to chronic hypoxia

Since a constant supply of oxygen is essential to sustain life, organisms have evolved multiple defence mechanisms to ensure maintenance of the delicate balance between oxygen supply and demand. However, this homeostatic balance is perturbed in response to a severe impairment of oxygen supply, thereby activating maladaptive signalling cascades that result in cardiac damage. Past research efforts have largely focused on determining the pathophysiological effects of severe lack of oxygen. By contrast, and as reviewed here, exposure to moderate chronic hypoxia may induce cardioprotective properties. The hypothesis put forward is that chronic hypoxia triggers regulatory pathways that mediate long-term cardiac metabolic remodelling, particularly at the transcriptional level. The novel proposal is that exposure to chronic hypoxia triggers (a) oxygen-sensitive transcriptional modulators that induce a switch to increased carbohydrate metabolism (fetal gene programme) and (b) enhanced mitochondrial respiratory capacity to sustain and increase efficiency of mitochondrial energy production. These compensatory protective mechanisms preserve contractile function despite hypoxia.

Hypoxia tolerance in mammals and birds: from the wilderness to the clinic

All mammals and birds must develop effective strategies to cope with reduced oxygen availability. These animals achieve tolerance to acute and chronic hypoxia by (a) reductions in metabolism, (b) the prevention of cellular injury, and (c) the maintenance of functional integrity. Failure to meet any one of these tasks is detrimental. Birds and mammals accomplish this triple task through a highly coordinated, systems-level reconfiguration involving the partial shutdown of some but not all organs. This reconfiguration is achieved through a similarly complex reconfiguration at the cellular and molecular levels. Reconfiguration at these various levels depends on numerous factors that include the environment, the degree of hypoxic stress, and developmental, behavioral, and ecological conditions. Although common molecular strategies exist, the cellular and molecular changes in any given cell are very diverse. Some cells remain metabolically active, whereas others shut down or rely on anaerobic metabolism. This cellular shutdown is temporarily regulated, and during hypoxic exposure, active cellular networks must continue to control vital functions. The challenge for future research is to explore the cellular mechanisms and conditions that transform an organ or a cellular network into a hypometabolic state, without loss of functional integrity. Much can be learned in this respect from nature: Diving, burrowing, and hibernating animals living in diverse environments are masters of adaptation and can teach us how to deal with hypoxia, an issue of great clinical significance.

Cardiac adaptation to chronic high-altitude hypoxia: beneficial and adverse effects

This review deals with the capability of the heart to adapt to chronic hypoxia in animals exposed to either natural or simulated high altitude. From the broad spectrum of related issues, we focused on the development and reversibility of both beneficial and adverse adaptive myocardial changes. Particular attention was paid to cardioprotective effects of adaptation to chronic high-altitude hypoxia and their molecular mechanisms. Moreover, interspecies and age differences in the cardiac sensitivity to hypoxia-induced effects in various experimental models were emphasized.

Attenuation of post-ischemia reperfusion injury by thaliporphine and morphine in rat hearts

Pretreatment with thaliporphine before ischemia affords cardioprotective effects against reperfusion injury via antioxidant activity. This study evaluated whether thaliporphine administered at a certain period after myocardial ischemia conferred the same cardioprotection and assessed its possible new mechanism. The left main coronary artery of anaesthetized rats was occluded for 1 h and then reperfused for 2 h. Thaliporphine was administered at 10 min before reperfusion. Controls received saline only. Morphine, a nonselective opioid receptor agonist, was used as reference compound at 0.3 mg/kg. Thaliporphine at 0.05 and 0.5 mg/kg were found to reduce the infarct size. Recovery of cardiac function was higher in thaliporphine (0.5 mg/kg) group, as assessed by a significant improvement in the rates of pressure development (+dp/dt (max)). This compound also reduced plasma creatine kinase and cardiac MPO activity. These protective effects afforded by thaliporphine were diminished by the opioid receptor antagonists (naloxone or naltrexone) and by the mitochondrial K(ATP) blocker 5HD. In comparison, morphine reduced infarct size and MPO activity in the myocardium but produced slightly improvement in cardiac function after ischemia-reperfusion. These results demonstrate that reperfusion therapy with thaliporphine protect cardiac injury through further mechanism via activation of opioid receptor and opening of mitochondrial K(ATP) channels as morphine but with stronger activity.

Inducible nitric oxide synthase contributes to intermittent hypoxia against ischemia/reperfusion injury

AIM

To investigate the role of inducible nitric oxide synthase (iNOS)-derived nitric oxide (NO) in the cardioprotection of intermittent hypoxia (IH) against ischemia/reperfusion (I/R) injury.

METHODS

Langendorff-perfused isolated rat hearts were used to measure variables of left ventricular function during baseline perfusion, ischemia, and reperfusion period. Nitrate plus nitrite (NOx) content in myocardium was measured using a biochemical method. iNOS mRNA and protein expression in rat left ventricles were detected using reverse transcription polymerase chain reaction (RT-PCR) and Western blot, respectively.

RESULTS

Myocardial function recovered better in IH rat hearts than in normoxic control hearts. The iNOS-selective inhibitor aminoguanidine (AG) (100 micromol/L) significantly inhibited the protective effects of IH, but had no influence on normoxic rat hearts. The baseline content of NOx in IH hearts was higher than that in normoxic hearts. After 30 min ischemia, the NOx level in normoxic hearts increased compared to the corresponding baseline level, whereas there was no significant change in IH hearts. However, the NOx level in IH hearts was still higher than that of normoxic hearts during ischemia and reperfusion period. AG 100 micromol/L significantly diminished the NOx content in IH and normoxic hearts during ischemia and reperfusion period. The baseline levels of iNOS mRNA and protein in IH hearts were higher than those of normoxic hearts. Compared to the corresponding baseline level, iNOS mRNA and protein levels in normoxic rat hearts increased and those in IH rat hearts decreased after reperfusion. The addition of AG 100 micromol/L significantly decreased iNOS mRNA and protein expression in IH rat hearts after I/R.

CONCLUSION

IH upregulated the baseline level of iNOS mRNA and protein expression leading to an increase in NO production, which may play an important role in the cardiac protection of IH against I/R injury.

Intermittent high altitude hypoxia protects the heart against lethal Ca2+ overload injury

Adaptation to intermittent high altitude (IHA) hypoxia can protect the heart against ischemia-reperfusion injury. In view of the fact that both Ca2+ paradox and ischemia-reperfusion injury are associated with the intracellular Ca2+ overload, we tested the hypothesis that IHA hypoxia may protect hearts against Ca2+ paradox-induced lethal injury if its cardioprotection bases on preventing the development of intracellular Ca2+ overload. Langendorff-perfused hearts from normoxic and IHA hypoxic rats were subjected to Ca2+ paradox (5 min of Ca2+ depletion followed by 30 min of Ca2+ repletion) and the functional, biochemical and pathological changes were investigated. The Ca2+ paradox incapacitated the contractility of the normoxic hearts, whereas the IHA hypoxic hearts significantly preserved contractile activity. Furthermore, the normoxic hearts subjected to Ca2+ paradox exhibited a marked reduction in coronary flow, increase in lactate dehydrogenase release, and severe myocyte damage. In contrast, these changes were significantly prevented in IHA hypoxic hearts. We, then, tested and confirmed our hypothesis that the protective mechanisms are mediated by mitochondria ATP-sensitive potassium channels (mitoKATP) and Ca2+/calmodulin-dependent protein kinase II (CaMKII), as the protective effect of IHA hypoxia was abolished by 5-hydroxydecanoate, a selective mitoKATP blocker, and significantly attenuated by KN-93, a CaMKII inhibitor. In conclusion, our studies offer for the first time that IHA hypoxia confers cardioprotection against the lethal injury of Ca2+ paradox and give biochemical evidence for the protective mechanism of IHA hypoxia. We propose that researches in this area may lead a preventive regimen against myocardial injury associated with Ca2+ overload.

Role of dual-site phospholamban phosphorylation in intermittent hypoxia-induced cardioprotection against ischemia-reperfusion injury

Cardioprotection by intermittent high-altitude (IHA) hypoxia against ischemia-reperfusion (I/R) injury is associated with Ca(2+) overload reduction. Phospholamban (PLB) phosphorylation relieves cardiac sarcoplasmic reticulum (SR) Ca(2+)-pump ATPase, a critical regulator in intracellular Ca(2+) cycling, from inhibition. To test the hypothesis that IHA hypoxia increases PLB phosphorylation and that such an effect plays a role in cardioprotection, we compared the time-dependent changes in the PLB phosphorylation at Ser(16) (PKA site) and Thr(17) (CaMKII site) in perfused normoxic rat hearts with those in IHA hypoxic rat hearts submitted to 30-min ischemia (I30) followed by 30-min reperfusion (R30). IHA hypoxia improved postischemic contractile recovery, reduced the maximum extent of ischemic contracture, and attenuated I/R-induced depression in Ca(2+)-pump ATPase activity. Although the PLB protein levels remained constant during I/R in both groups, Ser(16) phosphorylation increased at I30 and 1 min of reperfusion (R1) but decreased at R30 in normoxic hearts. IHA hypoxia upregulated the increase further at I30 and R1. Thr(17) phosphorylation decreased at I30, R1, and R30 in normoxic hearts, but IHA hypoxia attenuated the depression at R1 and R30. Moreover, PKA inhibitor H89 abolished IHA hypoxia-induced increase in Ser(16) phosphorylation, Ca(2+)-pump ATPase activity, and the recovery of cardiac performance after ischemia. CaMKII inhibitor KN-93 also abolished the beneficial effects of IHA hypoxia on Thr(17) phosphorylation, Ca(2+)-pump ATPase activity, and the postischemic contractile recovery. These findings indicate that IHA hypoxia mitigates I/R-induced depression in SR Ca(2+)-pump ATPase activity by upregulating dual-site PLB phosphorylation, which may consequently contribute to IHA hypoxia-induced cardioprotection against I/R injury.

Increased expression and altered subcellular distribution of PKC-delta in chronically hypoxic rat myocardium: involvement in cardioprotection

We examined the role of protein kinase C (PKC) in the cardioprotective mechanism induced by long-term adaptation to chronic intermittent hypoxia. Adult male Wistar rats were exposed to hypobaric hypoxia of 7,000 m for 8 h/day, 5 days/wk; the total number of exposures was 24-32. A control group was kept under normoxic conditions. Western blot analysis of PKC isoforms-delta and -epsilon was performed in the cytosol and three particulate fractions of left ventricular myocardium. Infarct size was determined in open-chest animals subjected to 20-min coronary artery occlusion and 3-h reperfusion. The PKC inhibitors chelerythrine (1 or 5 mg/kg) or rottlerin (selective for PKC-delta isoform; 0.3 mg/kg) were administered intravenously as a single bolus 15 min before ischemia. Chronic hypoxia had no effect on the expression and distribution of PKC-epsilon. The relative amount of PKC-delta increased in the cytosol and nuclear-cytoskeletal, mitochondrial, and microsomal fractions of chronically hypoxic myocardium by 100%, 212%, 237%, and 146%, respectively, compared with corresponding normoxic values. Chronic hypoxia decreased the size of myocardial infarction (normalized to the area at risk) by about one-third on the average (P < 0.05). Both doses of chelerythrine tended to reduce infarction in controls, and only the high dose completely abolished the improvement of ischemic tolerance in hypoxic hearts (P < 0.05). Rottlerin attenuated the infarct size-limiting effect of chronic hypoxia (P < 0.05), and it had no effect in controls. These results suggest that chronic intermittent hypoxia-induced cardioprotection in rats is partially mediated by PKC-delta; the contribution of other isoforms remains to be determined.

Intermittent hypoxia increases exercise tolerance in elderly men with and without coronary artery disease

BACKGROUND

Intermittent hypoxia has been suggested to increase exercise tolerance by enhancing stress resistance and improving oxygen delivery. Because the improvement of exercise tolerance reduces mortality in the elderly with and without coronary artery disease intermittent hypoxia might be a valuable preventive and therapeutic tool. However, controlled studies are lacking.

METHODS AND RESULTS

Sixteen males (50-70 years, 8 with and 8 without prior myocardial infarction) were randomly assigned in a double-blind fashion to receive 15 sessions of passive intermittent hypoxia (hypoxia group) or normoxia (control group) within 3 weeks. For the hypoxia group each session consisted of three to five hypoxic (14-10% oxygen) periods (3-5 min) with 3-min normoxic intervals. Controls inhaled only normoxic air in the same way. Exercise tests were performed before and after the 3-week breathing program. After 3 weeks of intermittent hypoxia peak oxygen consumption had increased compared to normoxic conditions (+ 6.2% vs.-3%, p < 0.001). This improvement was closely related to the enhanced arterial oxygen content after hypoxia (r = 0.9, p < 0.001). Both higher haemoglobin concentration and less arterial oxygen desaturation during exercise contributed to the increase in arterial oxygen content. During sub-maximal exercise (cycling at 1 W/kg) heart rate, systolic blood pressure, blood lactate concentration, and the rating of perceived exertion were diminished after intermittent hypoxia compared to control conditions (all p < 0.05). Changes in responses to exercise after intermittent hypoxia were similar in subjects with and without prior myocardial infarction.

CONCLUSIONS

Three weeks of passive short-term intermittent hypoxic exposures increased aerobic capacity and exercise tolerance in elderly men with and without coronary artery disease.

Intermittent hypoxia protects the rat heart against ischemia/reperfusion injury by activating protein kinase C

The aim of this study was to investigate whether and how protein kinase C (PKC) was involved in the protection afforded by intermittent hypoxia (IH) and the subcellular distribution of different PKC isozymes in rat left ventricle. Post-ischemic recovery of left ventricular developed pressure and +/-dP/dtmax in IH hearts were higher than those of normoxic hearts. Chelerythrine (CHE, 5 microM), a PKC antagonist, significantly inhibited the protective effects of IH, but had no influence on normoxic hearts. CHE significantly reduced the effect of IH on the time to maximal contracture (Tmc), but had no significant effect on the amplitude of maximal contracture (Amc) in IH group. In isolated normoxic cardiomyocytes, [Ca(2+)](i), measured as arbitrary units of fluorescence ratio (340 nm/380 nm) of fura-2, gradually increased during 20 min simulated ischemia and kept at high level during 30 min reperfusion. However, [Ca(2+)](i) kept at normal level during simulated ischemia and reperfusion in isolated IH cardiomyocytes. In normoxic myocytes, [Na(+)](i), indicated as actual concentration undergone calibration, gradually increased during 20 min simulated ischemia and quickly declined to almost the same level as that of pre-ischemia during 30 min simulated reperfusion. However, in IH myocytes, [Na(+)](i) increased to a level lower than the corresponding of normoxic myocytes during simulated ischemia and gradually reduced to the similar level as that of normoxic myocytes after simulated reperfusion. 5 microM CHE greatly increased the levels of [Ca(2+)](i) and [Na(+)](i) during ischemia and reperfusion in normoxic and IH myocytes. In addition, we demonstrated that IH up-regulated the baseline protein expression of particulate fraction of PKC-alpha, epsilon, delta isozymes. There is no significant difference of protein expression of PKC-alpha, epsilon, delta isozymes in cytosolic fraction between IH and normoxic group. The above results suggested that PKC contributed to the cardioprotection afforded by IH against ischemia/reperfusion (I/R) injury; the basal up-regulation of the particulate fraction of PKC-alpha, epsilon, delta isozymes in IH rat hearts and the contribution of PKC to the elimination of calcium and sodium overload might underlie the mechanisms of cardioprotection by IH.

Intermittent hypoxic training protects canine myocardium from infarction

This investigation examined cardiac protective effects of normobaric intermittent hypoxia training. Six dogs underwent intermittent hypoxic training for 20 consecutive days in a normobaric chamber ventilated intermittently with N2 to reduce fraction of inspired oxygen (FiO2) to 9.5%-10%. Hypoxic periods, initially 5 mins and increasing to 10 mins, were followed by 4-min normoxic periods. This hypoxia-normoxia protocol was repeated, initially 5 times and increasing to 8 times. The dogs showed no discomfort during intermittent hypoxic training. After 20 days of hypoxic training, the resistance of ventricular myocardium to infarction was assessed in an acute experiment. The left anterior descending (LAD) coronary artery was occluded for 60 mins and then reperfused for 5 hrs. At 30 mins of LAD occlusion, radioactive microspheres were injected through a left atrial catheter to assess coronary collateral blood flow into the ischemic region. After 5 hrs reperfusion, the heart was dyed to delineate the area at risk (AAR) of infarction and stained with triphenyl tetrazolium chloride to identify infarcted myocardium. During LAD occlusion and reperfusion, systemic hemodynamics and global left ventricular function were stable. Infarction was not detected in 4 hearts and was 1.6% of AAR in the other 2 hearts. In contrast, 6 dogs sham-trained in a chamber ventilated with compressed air and 5 untrained dogs subjected to the same LAD occlusion/reperfusion protocol had infarcts of 36.8% +/- 5.8% and 35.2% +/- 9.5% of the AAR, respectively. The reduction in infarct size of four of the six hypoxia-trained dogs could not be explained by enhanced collateral blood flow to the AAR. Hypoxia-trained dogs had no ventricular tachycardia or ventricular fibrillation. Three sham-trained dogs had ventricular tachycardia and two had ventricular fibrillation. Three untrained dogs had ventricular fibrillation. In conclusion, intermittent hypoxic training protects canine myocardium from infarction and life-threatening arrhythmias during coronary artery occlusion and reperfusion. The mechanism responsible for this potent cardioprotection merits further study.

Intermittent hypoxia attenuates ischemia/reperfusion induced apoptosis in cardiac myocytes via regulating Bcl-2/Bax expression

Intermittent hypoxia has been shown to provide myocardial protection against ishemia/reperfusion-induced injury. Cardiac myocyte loss through apoptosis has been reported in ischemia/reperfusion injury. Our aim was to investigate whether intermittent hypoxia could attenuate ischemia/reperfusion-induced apoptosis in cardiac myocytes and its potential mechanisms. Adult male Sprague-Dawley rats were exposed to hypoxia simulated 5000 m in a hypobaric chamber for 6 h/day, lasting 42 days. Normoxia group rats were kept under normoxic conditions. Isolated perfused hearts from both groups were subjected to 30 min of global ischemia followed by 60 min reperfusion. Incidence of apoptosis in cardiac myocytes was determined by terminal deoxynucleotidyl transferase mediated dUTP nick end labeling (TUNEL) and DNA agarose gel electrophoresis. Expressions of apoptosis related proteins, Bax and Bcl-2, in cytosolic and membrane fraction were detected by Western Blotting. After ischemia/reperfusion, enhanced recovery of cardiac function was observed in intermittent hypoxia hearts compared with normoxia group. Ischemia/reperfusion-induced apoptosis, as evidenced by TUNEL-positive nuclei and DNA fragmentation, was significantly reduced in intermittent hypoxia group compared with normoxia group. After ischemia/reperfusion, expression of Bax in both cytosolic and membrane fractions was decreased in intermittent hypoxia hearts compared with normoxia group. Although ischemia/reperfusion did not induce changes in the level of Bcl-2 expression in cytosolic fraction between intermittent hypoxia and normoxia groups, the expression of Bcl-2 in membrane fraction was upregulated in intermittent hypoxia group compared with normoxia group. These results indicated that the cardioprotection of intermittent hypoxia against ischemia/reperfusion injury appears to be in part due to reduce myocardial apoptosis. Intermittent hypoxia attenuated ischemia/reperfusion-induced apoptosis via increasing the ratio of Bcl-2/Bax, especially in membrane fraction.

Differential effects of opioid peptides on myocardial ischemic tolerance

BACKGROUND

Opioid peptides, which can induce mammalian hibernation, may provide protection against subcellular and molecular changes during hypothermic myocardial ischemia. This study examined the differential effects of the three known myocyte opioid receptors, Mu (micro), Delta (delta), and Kappa (kappa), in augmenting myocardial ischemic tolerance.

METHODS

Control hearts (CH) were compared to hearts pretreated with either the micro-agonist, fentanyl, the delta-agonist, DADLE, or delta-antagonist, NTB, or the kappa-agonist, U50488H (U50), or kappa-antagonist, nor-BNI. The percent return of isovolemic developed pressure (LVDP), myocardial oxygen consumption (MVO(2)), and coronary flow (CF) following 2 h of global hypothermic cardioplegic ischemia were recorded in isolated Langendorff perfused hearts.

RESULTS

At 45 min of reperfusion, hearts pretreated with either DADLE or U50488H demonstrated significantly improved functional recovery versus controls (P < 0.05) and significantly depressed recovery with NTB or nor-BNI pretreatment (P < 0.05). Pretreatment with fentanyl was not significantly different than controls. Furthermore, DADLE, U50488H, or fentanyl resulted in increased MVO(2) versus controls (P < 0.05). There was no difference in CF between all groups.

CONCLUSIONS

This study demonstrates that the micro-receptor does not appear to confer a beneficial effect. However, selective delta- and kappa-agonists provide significant myocardial protection. Moreover, hearts pretreated with an opioid antagonist showed a marked decrement in both functional and metabolic integrity. These results taken together would imply a positive and negative constitutive role of delta- and kappa-opioids in the regulation of myocardial ischemic tolerance. This utilization of opioid receptor stimulation may have profound clinical applications.

Effects of Chronic Intermittent Hypoxia on the Hemodynamics of Systemic Circulation in Rats

We examined the effects of chronic intermittent hypoxia (IH) on the hemodynamics of systemic circulation in rat. Chronic IH has no effect on the hemodynamics in the normoxia condition, but it could effectively prevent the fall of hemodynamics during acute hypoxia.

Chronic intermittent hypoxia enhances ventilatory long-term facilitation in awake rats

This study examined the effect of chronic intermittent hypoxia (CIH: 5 min 11-12% O2/5 min air, 12 h/night, 7 nights) on ventilatory long-term facilitation (LTF) and determined the persistence period of this CIH effect in awake rats. LTF, elicited by 5 or 10 episodes of 5 min 12% O2, was measured four times in the same Sprague-Dawley rats by plethysmography, before and 8 h, 3 days, and 7 days after CIH treatment. Resting ventilation was unchanged after CIH. Five episodes of 12% O2 did not initially elicit LTF but elicited LTF (23.5 +/- 1.4% above baseline) 8 h after CIH, which partially remained at 3 days (11.4 +/- 2.2%, P < 0.05) and disappeared at 7 days. Ten episodes initially elicited LTF (17.7 +/- 1.1%, 45-min duration) and elicited an enhanced LTF (29.1 +/- 1.5%, 75 min) 8 h after CIH. These results demonstrated that CIH enhanced ventilatory LTF in conscious, freely behaving rats in two ways: 1) a previously ineffective protocol induced LTF; and 2) LTF magnitude was increased and LTF duration prolonged, and this CIH effect on LTF persisted for at least 3 days.

ATP-dependent potassium channels involved in the cardiac protection induced by intermittent hypoxia against ischemia/reperfusion injury

The aim of this study was to investigate the protection afforded by intermittent hypoxia (IH) against ischemia/reperfusion injury and its effects on calcium homeostasis during ischemia/reperfusion. The roles of KATP channels in these two actions were to be explored. Isolated hearts from IH and normoxic rats were subjected to 30 min global ischemia followed by 30 min reperfusion. Cardiac function was less deteriorated during ischemia and reperfusion in the IH rat hearts compared to normoxia rat hearts. Amplitude of the maximal contracture during ischemia was lower, while time to maximal contracture was extended in IH hearts. Post-ischemic recovery of left ventricular developed pressure and +/-dP/dtmax were higher in IH hearts than in normoxic hearts. KATP antagonist glibenclamide (10 microM) completely abolished these protective effects of IH, but had no appreciable influence on normoxic hearts. In cardiomyocytes isolated from normoxic hearts, [Ca2+]i, measured as arbitrary units of fluorescence ratio (340 nm/380 nm) of fura-2, gradually increased during 20 min simulated ischemia and kept at high level during 30 min reperfusion (1.081 +/- 0.004 and 1.088 +/- 0.006 respectively, p<0.01 vs pre-ischemia perfusion). However, in cardiomyocytes isolated from IH hearts, [Ca2+]i kept at normal level during ischemia and reperfusion (1.012 +/- 0.006 and 1.021 +/- 0.002 respectively, P>0.05 vs pre-ischemia perfusion). 10 microM glibenclamide and 100 microM 5-hydroxydecanoate (a selective mitochondria KATP antagonist) respectively abolished this effect of IH; calcium overloading reappeared during ischemia (1.133 +/- 0.007 and 1.118 +/- 0.007 respectively, P<0.01) and reperfusion (1.091 +/- 0.004 and 1.095 +/- 0.012 respectivly, P<0.01). However they had no effects on simulated ischemia and reperfusion-induced calcium overloading in normoxic myocytes. 50 microM pinacidil, a KATP opener, attenuated calcium overloading during ischemia and reperfusion in normoxic myocytes, but had no effect on [Ca2+]i change in IH myocytes. These results suggested that KATP channels contributed to the cardiac protection induced by IH against ischemia/reperfusion injury; the elimination of calcium overloading during ischemia/reperfusion by IH might underlie the mechanism of protection.

Interval hypoxic training

Interval hypoxic training (IHT) is a technique developed in the former Soviet Union, that consists of repeated exposures to 5-7 minutes of steady or progressive hypoxia, interrupted by equal periods of recovery. It has been proposed for training in sports, to acclimatize to high altitude, and to treat a variety of clinical conditions, spanning from coronary heart disease to Cesarean delivery. Some of these results may originate by the different effects of continuous vs. intermittent hypoxia (IH), which can be obtained by manipulating the repetition rate, the duration and the intensity of the hypoxic stimulus. The present article will attempt to examine some of the effects of IH, and, whenever possible, compare them to those of typical IHT. IH can modify oxygen transport and energy utilization, alter respiratory and blood pressure control mechanisms, induce permanent modifications in the cardiovascular system. IHT increases the hypoxic ventilatory response, increase red blood cell count and increase aerobic capacity. Some of these effects might be potentially beneficial in specific physiologic or pathologic conditions. At this stage, this technique appears interesting for its possible applications, but still largely to be explored for its mechanisms, potentials and limitations.

Invited review: Physiological and pathophysiological responses to intermittent hypoxia

This mini-review summarizes the physiological adaptations to and pathophysiological consequences of intermittent hypoxia with special emphasis given to the pathophysiology associated with obstructive sleep apnea. Intermittent hypoxia is an effective stimulus for evoking the respiratory, cardiovascular, and metabolic adaptations normally associated with continuous chronic hypoxia. These adaptations are thought by some to be beneficial in that they may provide protection against disease as well as improve exercise performance in athletes. The long-term consequences of chronic intermittent hypoxia may have detrimental effects, including hypertension, cerebral and coronary vascular problems, developmental and neurocognitive deficits, and neurodegeneration due to the cumulative effects of persistent bouts of hypoxia. Emphasis is placed on reviewing the available data on intermittent hypoxia, making extensions from applicable information from acute and chronic hypoxia studies, and pointing out major gaps in information linking the genomic and cellular responses to intermittent hypoxia with physiological or pathophysiological responses.

Ischemic tolerance of the heart by adaptation to chronic hypoxia is suppressed by high subchronic carbon monoxide exposure

This study was designed to investigate whether exposure to carbon monoxide (CO) could alter the ischemic tolerance induced by chronic hypoxia. We aimed to determine whether chronic hypoxia-induced cardiovascular adaptation was modified during the return to normoxia or by subchronic CO exposure. The degree of resistance to an in vitro transient ischemia was measured, using the Langendorff method, in hearts from rats previously exposed to chronic hypoxic hypoxia and/or subchronic CO exposure to 600 ppm. Chronic hypoxia decreased ischemic contracture (15.6 +/- 04.9 vs. 60.8 +/- 07.7%) and improved both contractile recovery (59.6 +/- 07.3 vs. 21.8 +/- 06.8%) and ventricular arrhythmia during reperfusion (0 vs. 45%) compared to a control normoxic group. However, in our chronic hypoxia regression model many parameters returned near to control values except for the persistence of cardiomegaly, a significant decrease in both ischemic contracture (22.0 +/- 04.9 vs. 60.8 +/- 07.7%), and ventricular tachycardia (25 vs. 45%). CO exposure alone increased the coronary flow and improved both contractile recovery (42.6 +/- 7.2 vs. 21.8 +/- 6.8%) and ventricular arrhythmia (16.7 vs. 45%) without altering the action potential shape. These two models causing tissue hypoxia induced the same degree of polycythemia or cardiomegaly and provided similar ischemic tolerance. CO exposure after chronic hypoxia exacerbated ischemic contracture (69.3 +/- 10.5 vs. 22.0 +/- 14.5%) and ventricular tachycardia incidence (100 vs. 50%) but with significant alteration in contractile recovery (12.7 +/- 10.5%) compared to the chronic hypoxia or CO exposure. Thus, CO exposure completely suppressed the chronic hypoxia-induced ischemic tolerance.

Adaptation to high altitude hypoxia protects the rat heart against ischemia-induced arrhythmias. Involvement of mitochondrial K(ATP) channel

The aim was to determine whether adaptation to chronic hypoxia protects the heart against ischemic arrhythmias and whether ATP-dependent potassium channels (K(ATP)) play a role in the antiarrhythmic mechanism. Adult male rats were adapted to intermittent high altitude hypoxia (5000 m, 4 h/day) and susceptibility to ischemia-induced ventricular arrhythmias was evaluated in the Langendorff-perfused hearts subjected to either an occlusion of the coronary artery for 30 min or pre-conditioning by brief occlusion of the same artery prior to 30-min reocclusion. In separate groups, either a K(ATP) blocker, glibenclamide (10 micromol/l), or a mitochondrial K(ATP) opener, diazoxide (50 micromol/l), were added to a perfusion medium 20 min before the occlusion. Adaptation to hypoxia reduced the total number of ventricular arrhythmias by 64% as compared with normoxic controls. Preconditioning by a single 3-min coronary artery occlusion was antiarrhythmic only in the normoxic group, while two occlusion periods of 5 min each were needed to pre-condition the hypoxic hearts. Glibenclamide increased the number of arrhythmias in the normoxic hearts from 1316+/-215 to 2091+/-187 (by 59%) and in the hypoxic group from 636+/-103 to 1777+/-186 (by 179%). In contrast, diazoxide decreased the number of arrhythmias only in the normoxic group from 1374+/-96 to 582+/-149 (by 58%), while its effect in the hypoxic group was not significant. It is concluded that long-term adaptation of rats to high altitude hypoxia decreases the susceptibility of their hearts to ischemic arrhythmias and increases an antiarrhythmic threshold of pre-conditioning. The mitochondrial K(ATP) channel, rather than the sarcolemmal K(ATP) channel, appears to be involved in the protective mechanism afforded by adaptation.

Cardioprotection of preconditioning by metabolic inhibition in the rat ventricular myocyte. Involvement of kappa-opioid receptor

To determine whether opioid receptors (ORs) are involved in the delayed cardioprotection of ischemic preconditioning (IP), the effect of severe metabolic inhibition (MI) with a glucose-free buffer that contained sodium cyanide and 2-deoxy-D-glucose on the viability of isolated rat ventricular myocytes was first determined 20 hours after preconditioning with a sublethal metabolic inhibition (MIP) with a glucose-free buffer that contained 2-deoxy-D-glucose and lactate for 30 minutes in the presence of OR antagonists. With the use of trypan blue exclusion as an index of cell viability, severe MI killed >60% of the cells and the value increased significantly after MIP. In the presence of 5x10(-6) mol/L nor-binaltorphimine (nor-BNI), a selective kappa-OR antagonist, but not 5x10(-6) mol/L CTOP, a selective mu-OR antagonist, or 5x10(-6) mol/L naltrindole, a selective delta-OR antagonist, the cardioprotection of MIP was significantly attenuated. To verify the role of kappa-OR, we studied the effects of severe MI after pretreatment with the kappa-OR agonist U50,488H (UP) for 30 minutes. U50,488H at 3x10(-6) to 1x10(-4) mol/L increased cell viability concentration-dependently with an EC50 of 3.311x10(-6) mol/L. In the presence of 5x10(-6) nor-BNI, the cardioprotection of UP (3x10(-5) mol/L) was blocked. A time course study showed that UP-induced cardioprotection occurred in 2 windows: the first occurred approximately 1 hour later and the other occurred 16 to 20 hours later. Additional studies on cell contraction and intracellular Ca2+ ([Ca2+]i) revealed that both UP and MIP attenuated the inhibitory effects of severe MI on contractility and electrically induced [Ca2+]i transient in single ventricular myocytes. On blockade of protein kinase C, the delayed cardioprotections of UP and MIP were significantly attenuated. In conclusion, the results of the present study have provided evidence that kappa-OR mediates the cardioprotection of MIP, which may involve protein kinase C and [Ca2+]i.