Ouabain: temporal relationship between the inotropic effect and the in vitro binding to, and dissociation from, (Na + + K + )- activated ATPase

Is Heart Rate a Norepiphenomenon in Heart Failure?

There has been an increased focus on heart rate as a target in the management of cardiovascular disease and more specifically in heart failure with preserved ejection fraction in recent years with several studies showing the benefit of a lower resting heart rate on outcomes. This review paper examines the pathophysiology behind the benefits of lowering heart rate in heart failure and also the evidence for and against the pharmacological agents available to achieve this.

WITHDRAWN: Shengmai (a traditional Chinese herbal medicine) for heart failure

Cochrane Heart withdrew this review as the current author team is unable to progress. This review is considered low priority and therefore this review is not open for new authors.

The editorial group responsible for this previously published document have withdrawn it from publication.

The use of digoxin in patients with worsening chronic heart failure: reconsidering an old drug to reduce hospital admissions

Digoxin is the oldest cardiac drug still in contemporary use, yet its role in the management of patients with heart failure (HF) remains controversial. A purified cardiac glycoside derived from the foxglove plant, digoxin increases ejection fraction, augments cardiac output, and reduces pulmonary capillary wedge pressure without causing deleterious increases in heart rate or decreases in blood pressure. Moreover, it is also a neurohormonal modulator at low doses. In the pivotal DIG (Digitalis Investigation Group) trial, digoxin therapy was shown to reduce all-cause and HF-specific hospitalizations but had no effect on survival. With the discovery of neurohormonal blockers capable of reducing mortality in HF with reduced ejection fraction, the results of the DIG trial were viewed as neutral, and the use of digoxin declined precipitously. Although modern drug and device-based therapies have dramatically improved the survival of ambulatory patients with HF, outcomes for patients with worsening chronic HF, defined as deteriorating signs and symptoms on standard therapy often leading to unscheduled clinic or emergency department visits or hospitalization, have largely remained unchanged over the past 2 decades. The available data suggest that a therapeutic trial of digoxin may be appropriate in patients with worsening chronic heart failure who remain symptomatic.

Antagonism of Cortex Periplocae extract-induced catecholamines secretion by Panax notoginseng saponins in cultured bovine adrenal medullary cells by drug combinations

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Chinese Medicine (TCM) operates on the general principle that compatible components of different herbal decoction may work together to synergistically enhance therapeutic efficacy or reduce adverse effects. Cortex Periplocae is an herb that has been used in TCM clinics for a long time in the treatment of chronic heart failure. However, recently, the use of this herb has been restricted because of widespread abuse and misapplications. Radix Notoginseng is another herb that is used in TCM because of its protective role on cardiomyocytes. From our previous studies on these two herbs in a mouse model, we observed an increased LD50 after oral administration of Cortex Periplocae extract (CPE) and Panax notoginseng saponins (PNS) in a ratio of 1:1 compared with Cortex Periplocae extract used alone.

AIM OF THE STUDY

This study aimed to investigate whether there are mutual synergistic effects of the two herbal extracts, CPE and PNS, on catecholamines (CAs) secretion, and their possible underlying mechanism(s) for such effects.

MATERIALS AND METHODS

CPE and PNS were quantified by the LC-MS/MS method. HPLC-ECD was used to determine the CAs secreted into the medium by bovine adrenal medulla cells (BAMCs) and calcium influx was measured using a Calcium 4 reagent kit.

RESULTS

We found that the stimulatory effect of CPE on CAs secretion was inhibited when used together with PNS. For a better clarification of the different constituents of the extracts, a quantitative analysis was carried out. Periplocin was found to be the main active component of CPE valued as 0.99% and saponins were the principal constituents of PNS. These results also showed that CPE increased the secretion of CAs in a dose-dependent manner while the actions of PNS were seen to be inhibitory. Periplocin monomer of CPE could be implicated for the actions of CPE since it plays the role of increasing the ACh-induced CAs secretion in a calcium-dependent manner. We therefore conclude that; CPE and PNS exert antagonistic effects in regulating the concentration of intracellular calcium.

CONCLUSIONS

PNS inhibits CPE-induced CAs secretion by suppressing calcium influx in bovine adrenal medulla cells while periplocin, one of the main components of CPE has the same secretagogue effect as CPE.

Shengmai (a traditional Chinese herbal medicine) for heart failure

BACKGROUND

This systemic review is an update of a review previously published in 2011. Heart failure is a major public health problem worldwide. Shengmai (a traditional Chinese herbal medicine) has long been used as a complementary treatment for heart failure in China.

OBJECTIVES

To assess the effects (both benefits and harms) of Shengmai for heart failure.

SEARCH METHODS

We searched CENTRAL and DARE on The Cochrane Library (2011, Issue 1), MEDLINE (1948 to March 2011), EMBASE (1980 to March 2011), AMED (1985 to August 2008) (AMED was not searched for the update as it is no longer available to the person conducting the searches), BIOSIS (1969 to March 2011), CBM (1978 to April 2011), VIP (1989 to April 2011) and CNKI (1979 to April 2011). We also handsearched Chinese journals. No language restrictions were applied.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of Shengmai plus usual treatment versus usual treatment alone or Shengmai versus placebo in treating heart failure, irrespective of blinding status, were included. More stringent inclusion criteria were applied in this update and only studies with a clear description of randomization methods and classified as true RCTs were included.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, assessed methodological quality and extracted data. Dichotomous and continuous data were calculated as relative risk (RR) and mean difference (MD) or standardized mean difference (SMD), respectively. A random-effects model and fixed-effect model were used to perform meta-analysis with and without heterogeneity, respectively.

MAIN RESULTS

Nine RCTs (600 patients) with seven comparing Shengmai plus usual treatment with usual treatment alone and three comparing Shengmai with placebo (one RCT contained three arms) were included in this updated review. Based upon the seven RCTs (494 patients), improvement of the New York Heart Association (NYHA) functional classification was more common in patients taking Shengmai plus usual treatment than in those receiving usual treatment alone (risk ratio 0.33, 95% confidence interval 0.23 to 0.47). Beneficial effects of Shengmai in treating heart failure were also observed on other outcomes, including an exercise test, ejection fraction, cardiac output, cardiac index and left ventricular end-systolic volume. The three RCTs (106 patients) which compared Shengmai with placebo reported an improvement in NYHA functional classification, ejection fraction, stroke volume, cardiac index and myocardial contractility. Three out of the nine RCTs reported mild adverse effects, and two patients were withdrawn due to the adverse effects. The results of this review should be interpreted with caution. This is due to the studies being of low quality, their small sample size, and the significant heterogeneity for certain outcomes including ejection fraction and cardiac output.

AUTHORS' CONCLUSIONS

Shengmai may be beneficial in treating heart failure, especially in terms of improving the NYHA functional classification with Shengmai plus usual treatment. However, the evidence for its effects on mortality and hospitalisation are not available yet. Therefore more studies, of higher quality and long-term follow-up, are needed to provide more evidence for the future use of Shengmai.

Shengmai (a traditional Chinese herbal medicine) for heart failure

BACKGROUND

Heart failure is a major public health problem worldwide. Shengmai (a traditional Chinese herbal medicine) has long been used as a complementary treatment for heart failure in China.

OBJECTIVES

To determine the effects (both benefits and harms) of Shengmai plus usual treatment versus usual treatment alone for heart failure.

SEARCH STRATEGY

We searched CENTRAL and DARE on The Cochrane Library (Issue 3, 2008), MEDLINE (1966 to August 2008), EMBASE (1984 to August 2008), AMED (1985 to August 2008) and BIOSIS (1997 to August 2008) and CBM (1978 to August 2008). We added two new Chinese databases for the update; VIP (1989 to September 2008) and CNKI (1979 to September 2008). We also handsearched Chinese journals. No language restrictions were applied.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of Shengmai plus usual treatment versus usual treatment alone or Shengmai versus placebo for heart failure, irrespective of blinding status, were included. More stringent inclusion criteria were applied in this update and only studies that have a clear description of randomisation methods are classed as true RCTs and hence included.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, assessed methodological quality and extracted data. Dichotomous and continuous data were calculated as relative risk (RR), and mean differences (MD) or standardized mean difference (SMD). Random-effect model and fixed-effect model were used to perform meta-analysis for with and without heterogeneity respectively.

MAIN RESULTS

Only six RCTs with a total of 440 patients were included in this updated review. Compared to usual treatment alone, Shengmai plus usual treatment in five trials indicated an improvement in NYHA classification (RR 0.37; 95% CI 0.25 to 0.54). Other benefits were observed, but were limited to low patient numbers and significant heterogeneity: ejection fraction, cardiac output, stroke volume, exercise test and ratio of peak early to late diastolic filling velocity. Only one RCT with 40 patients compared Shengmai to placebo, and improvements were seen in stroke volume, Heath and Cardic index and myocardial contractility. Two studies reported mild adverse effects, but no patients were withdrawn or needed medication due to these adverse effects.

AUTHORS' CONCLUSIONS

Shengmai may be beneficial for heart failure compared to placebo or plus usual treatment compared to usual treatment alone. However, long-term and more high quality studies are needed to provide clear evidence for the future use of Shengmai.

Heart failure management: the present and the future

Clinical heart failure has been defined for a long time as a clinical syndrome with symptoms and signs including shortness of breath, cyanosis, ascites, and edema. However, in recent years, with the thought of promoting early diagnosis and heart-failure prevention, the concept of heart failure has often been defined simply as a subject with severe LV dysfunction and a dilated left ventricle, or by some, defined by evidence of increased circulating levels of molecular markers of cardiac dysfunction, such as ANP and BNP. Heart failure has been considered an irreversible clinical end point. Current medical management for heart failure only relieves symptoms, slows deterioration, and prolongs life modestly. However, in the recent years, rejuvenation of the failing myocardium began to seem possible as the accumulating preclinical studies demonstrated that rejuvenating the myocardium at the molecular and cellular level can be achieved by gene therapy or stem cell transplantation. Here, we review selected novel modalities that have been shown in preclinical studies to exert beneficial effects in animal models of severe LV dysfunction and seem to have the potential to make an impact in the clinical practice of heart-failure management.

Shengmai (a traditional Chinese herbal medicine) for heart failure

BACKGROUND

Heart failure is a major public health problem world-wide. Shengmai (a traditional Chinese herbal medicine) has long been used as a complementary treatment for heart failure in China.

OBJECTIVES

To determine the effect (both benefits and harms) of shengmai plus usual treatment versus usual treatment alone for heart failure.

SEARCH STRATEGY

We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 2, 2005), MEDLINE (1966 to May 2005), EMBASE (1984 to March 2004), AMED (1985 to July 2005), Chinese BioMedical Literature Database(1978 to April 2004), DARE (Issue 2, 2005) and BIOSIS (1997 to 2004). Seventeen Chinese journals were also handsearched.

SELECTION CRITERIA

Trials of shengmai plus usual treatment versus usual treatment alone for heart failure were included. Randomized or quasi-randomized controlled trials, regardless of whether they were blinded, were included.

DATA COLLECTION AND ANALYSIS

Two reviewers selected trials, assessed methodological quality and extracted data independently. Dichotomous and continuous data were calculated as relative risk (RR), and weighted mean differences (WMD), respectively. No heterogeneity was detected between included trials. A fixed-effect model was used to perform meta-analysis.

MAIN RESULTS

Nineteen trials were included studies. Methodological quality of the included studies was low. Compared to usual treatment alone, shengmai plus usual treatment showed significant improvement in New York Heart Association classification of clinical status (RR 0.32; 95% CI 0.25 to 0.40), mortality (RR 0.25; 95% CI 0.07 to 0.86), and tumour necrosis factor-alpha (WMD -0.52; 95% CI -0.99 to -0.05). Improvements were also seen in hemodynanic tests (one trial, 100 participants). No adverse affects were reported in any of the included trials.

AUTHORS' CONCLUSIONS

It is possible that shengmai plus usual treatment may be beneficial compared to usual treatment alone for heart failure. However the evidence is weak because of the poor quality of the included trials. Long-term and high quality studies are needed to provide clear evidence for the future use of shengmai.

Standard therapies for pulmonary arterial hypertension

After half a century of clinical experience and research, management of pulmonary arterial hypertension remains a challenge. Currently, data to support the use of standard therapies for pulmonary arterial hypertension (oxygen supplementation, diuretics, digoxin, anticoagulation, and calcium channel blockers) are mostly retrospective, uncontrolled prospective, or derived from other diseases with similar but not identical manifestations. In the absence of any further prospective, controlled studies, it is reasonable to use these therapies when they are tolerated. When these therapies are poorly tolerated, however, the threshold for discontinuation should be low.

Digoxin in heart failure

Digoxin is an agent with a long history of use in the management of heart failure; its benefits have just been quantified in recent years. It has long been known that digoxin provides a small amount of inotropic augmentation; however, it is now realized that digoxin also modulates the neurohormonal activation that occurs in heart failure. Although long-term therapy with digoxin does not decrease mortality, it does provide clinical benefit in terms of improved exercise tolerance and decreased hospitalizations across all severities of heart failure. Serum concentrations of digoxin associated with clinical benefits are lower than previously recognized (0.8-1.0 ng/mL). Digoxin toxicity can be easily avoided by maintaining these relatively low serum concentrations, avoiding and aggressively treating hypokalemia, and being mindful of poor renal function and drug interactions that may result in digoxin accumulation.

Pharmacologic therapy for patients with chronic heart failure and reduced systolic function: review of trials and practical considerations

Heart failure (HF) is a complex clinical syndrome resulting from any structural or functional cardiac disorder impairing the ability of the ventricles to fill with or eject blood. The approach to pharmacologic treatment has become a combined preventive and symptomatic management strategy. Ideally, treatment should be initiated in patients at risk, preventing disease progression. In patients who have progressed to symptomatic left ventricular dysfunction, certain therapies have been demonstrated to improve survival, decrease hospitalizations, and reduce symptoms. The mainstay therapies are angiotensin-converting enzyme (ACE) inhibitors and beta-blockers (bisoprolol, carvedilol, and metoprolol XL/CR), with diuretics to control fluid balance. In patients who cannot tolerate ACE inhibitors because of angioedema or severe cough, valsartan can be substituted. Valsartan should not be added in patients already taking an ACE inhibitor and a beta-blocker. Spironolactone is recommended in patients who have New York Heart Association (NYHA) class III to IV symptoms despite maximal therapies with ACE inhibitors, beta-blockers, diuretics, and digoxin. Low-dose digoxin, yielding a serum concentration <1 ng/mL can be added to improve symptoms and, possibly, mortality. The combination of hydralazine and isosorbide dinitrate might be useful in patients (especially in African Americans) who cannot tolerate ACE inhibitors or valsartan because of hypotension or renal dysfunction. Calcium antagonists, with the exception of amlodipine, oral or intravenous inotropes, and vasodilators, should be avoided in HF with reduced systolic function. Amiodarone should be used only if patients have a history of sudden death, or a history of ventricular fibrillation or sustained ventricular tachycardia, and should be used in conjunction with an implantable defibrillator [corrected]. Finally, anticoagulation is recommended only in patients who have concomitant atrial fibrillation or a previous history of cerebral or systemic emboli.

The importance of early intervention in CHF--signs and symptom relief

Effective treatments of congestive heart failure (CHF) must not only reduce mortality, but should also reduce the severity of the signs and symptoms of the syndrome, as these can have a major impact on quality of life. Early intervention can help to make everyday activities easier for patients with CHF and may slow disease progression. This review provides an overview of the efficacies of various therapies in improving the signs and symptoms of CHF, with particular reference to recent data from randomised, double-blind studies of patients receiving the AT(1)-receptor blocker, candesartan cilexetil.

The development of positive inotropic agents for chronic heart failure: how have we gone astray?

Because cardiac contractility is impaired in chronic heart failure, many pharmacologic agents have been developed to increase the contractile state of the failing heart. These drugs produce impressive hemodynamic effects, but long-term therapy has failed to produce clinical benefits and has increased mortality in treated patients. This experience has led many physicians to suggest that positive inotropic therapy be abandoned as a therapeutic approach for heart failure. However, recent studies suggest that the efficacy and safety of many (if not all) positive inotropic drugs can be greatly enhanced by reducing the dose of these drugs. The importance of dose is dramatically illustrated by the results of trials with vesnarinone, which decreases mortality when used in low doses but increases mortality when administered in doses only twice as large. Although low doses of positive inotropic drugs may be clinically superior to high doses, it is not clear that these low doses exert significant inotropic effects. All positive inotropic drugs exert actions on the circulation in addition to stimulating the heart, and these ancillary properties may be particularly important at low doses of these drugs. Low doses of milrinone and pimobendan may act primarily to dilate peripheral blood vessels; low doses of digitalis may exert only neurohormonal effects, and low doses of vesnarinone may act as an antiarrhythmic agent. If the noninotropic actions of low doses account for the therapeutic benefits of these drugs, then the positive inotropic effects seen at high doses may be primarily responsible for their adverse effects.(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of binding to Na,K-ATPase in the tissue distribution of ouabain in guinea pigs

Ouabain binds specifically to Na,K-ATPase on the plasma membrane and therefore serves to measure the tissue concentration of Na,K-ATPase. We examined the role of ouabain binding to Na,K-ATPase in its overall tissue distribution. The tissue-to-plasma concentration ratio (Kp,vivo) was defined in each tissue after intravenous administration of 3H-ouabain in guinea pigs, and specific binding of ouabain to Na,K-ATPase was measured in tissue homogenate to obtain the dissociation constant and binding capacity in each tissue. A predicted tissue-to-plasma concentration ratio (Kp,vitro) was calculated using the obtained binding parameters and the volume of extracellular space in each tissue. The absolute values of Kp,vitro were comparable to those of Kp,vivo, except in brain. Regression analysis showed that the specific binding capacity of Na,K-ATPase in each tissue is the main factor in the tissue variation of Kp,vivo. Therefore, the binding of ouabain to Na,K-ATPase plays a significant role in the tissue distribution of ouabain.

Cardiotonic drugs inhibit purified mammalian acetylcholinesterase

Oxime- and non-oxime-related drugs, as well as cardiotonic drugs (CDs), have been used to treat the effects of organophosphorus (OP) poisoning. We conducted our experiments to determine what effects CDs may have on acetylcholinesterase (AChE), and how CDs interact with other treatment drugs as well as with OP-inhibited AChE. True AChE (EC 3.1.1.7) was purified from fetal bovine serum, and enzyme activity was measured according to Ellman et al. The CDs coumingine, cassaine, proscillaridin and convallatoxin were incubated with AChE at 550 microM at pH 7.6 and 25 degrees C. The CD ouabain was incubated with AChE at 500 microM. The CDs inhibited AChE by 97%, 89%, 10%, 7% and 6%, respectively. The mean AChE activities for these experiments, except for ouabain, were significantly different (P = 0.05) from their controls, as determined by the two-tailed Student's t-test. In a separate experiment, the oxime TMB-4.2Br (100 microM), which did not inhibit AChE, increased the inhibitory effect of proscillaridin from 4% to 11% (a 3.7-fold increase). When AChE was inhibited 39% with 37 nM VX, the addition of proscillaridin increased the inhibition to 51% (a 1.3-fold increase). When TMB-4 was added to the proscillaridin- and VX-inhibited AChE mixture, the inhibition decreased from 50% to 32% (a 0.37-fold decrease), whereas TMB-4 alone added to VX-inhibited AChE decreased the inhibition from 39% to 24% (a 0.38-fold decrease). The results show that TMB-4 increases the inhibition of AChE by proscillaridin. However, TMB-4 decreases the inhibition of AChE by VX and proscillaridin combined.(ABSTRACT TRUNCATED AT 250 WORDS)

Lipophilicity and pharmacodynamics of cardiotonic steroids in guinea-pig isolated heart muscle preparations

1. The inhibitory potency of cardiotonic steroids on myocardial Na+-K+-ATPase increases with increasing lipophilicity. Employing the inotropic action on guinea-pig isolated left atria, the relationship between lipophilicity, chemical structure and the pharmacodynamic properties of cardiac glycosides was further examined. Nineteen digitoxigenin- and digoxigenin-derivatives, whose lipophilic nature and inhibitory effects on the myocardial Na+-K+-ATPase have been previously investigated, were tested. 2. All steroids exhibited positive inotropic effects which varied with the lipophilicity of these drugs. The dependence of the relationship between these two parameters on structural transformations of the steroids showed qualitatively very close parallelism to that between lipophilicity and their inhibitory effects on myocardial Na+-K+-ATPase. 3. The positive inotropic effects and the inhibitory effects on myocardial Na+-K+-ATPase also correlated very well, exhibiting similar patterns in their respective correlations with the individual lipophilicity parameters. 4. It is inferred that (a) the positive inotropic effects of the cardiac glycosides vary with their lipophilicity, exhibiting trends similar to those shown for their inhibitory effects on myocardial Na+-K+-ATPase, (b) this interdependence is secondary to the influence of structural changes, particularly on the steroid nucleus, and (c) both the lipophilic nature and pharmacodynamic behaviour of the cardiac glycosides almost exclusively depend on the steroid nucleus itself.

Apparent cooperativity of [3H]ouabain binding to myocytes obtained from guinea-pig heart

Kinetics of [3H]ouabain binding to intact cardiac cells were examined using myocytes obtained from guinea-pig heart. In intact cells, the use of excess unlabeled ouabain results in an under-estimation of nonspecific binding, presumably due to cytotoxic effects of the unlabeled glycoside; estimation of the specific binding, as that to rapidly releasing sites yields more accurate results. Specific [3H]ouabain binding to myocytes is promoted by an increase in Na+ influx, indicating that normal intracellular Na+ concentration is insufficient to fully stimulate glycoside binding. High concentrations of [3H]ouabain seem to increase the apparent affinity of binding sites for the glycoside via increases in intracellular Na+ concentration resulting from sodium-pump inhibition; hence the binding reaction may be regarded as having a novel type of cooperativity. This cooperativity has kinetics different from those of classical positive cooperativity based on binding-site interactions, and is apparent with toxic concentrations of the glycoside that cause marked increases in intracellular Na+ concentrations.

Carp (Cyprinus carpio) heart has a high sensitivity to the positive inotropic effect of strophanthidin despite negative force-frequency relationships

1. The relationship between response of the heart to increased stimulation frequency and digitalis sensitivity was examined comparing the positive inotropic effect of strophanthidin and [3H]ouabain binding to sarcolemmal Na+, K+-activated adenosine triphosphatase (Na+, K+-ATPase) in carp heart, which showed a negative force-frequency relationship, and in guinea-pig heart, which has a positive relationship. 2. In ventricular muscle preparations isolated from carp heart, strophanthidin increased developed tension with a half-maximal effect observed at 0.31 microM, indicating a relatively high digitalis sensitivity of this preparation. 3. The positive inotropic effect was not altered by concentrations of propranolol sufficient to block beta-adrenergic receptors. 4. Specific binding of [3H]ouabain to homogenates obtained from ventricular muscle of carp heart showed a single class of binding sites with a Kd value of 26 nM. 5. Potency of strophanthidin to produce the positive inotropic effect and affinity of the binding sites for [3H]ouabain were both higher in carp heart compared to those in guinea-pig heart. 6. These results demonstrate a clear dissociation between the force-frequency relationship and the sensitivity of heart muscle to the positive inotropic effect of cardiotonic steroids. 7. The latter is primarily determined by affinity of sarcolemmal Na+, K+-ATPase for the cardiotonic steroids.

Species variation in the ouabain sensitivity of cardiac Na+/K+-ATPase. A possible role for membrane lipids

The role of membrane lipid composition on the modulation of ouabain sensitivity of cardiac Na+/K+-ATPase has been studied in vitro using several animal species. The animals can be grouped as ouabain-sensitive and ouabain-insensitive species. Ouabain-sensitive species (I50; 0.5-2.2 microM) include sheep, marmoset, pig and the guinea pig, whilst rat and mouse form the ouabain-insensitive group (I50; 100-105 microM). Although no species variation in the distribution of major phospholipid classes was observed, significant differences were apparent in the proportions of certain saturated and unsaturated phospholipid fatty acids. Thus, there was a marked increase in the relative proportion of docosahexaenoic (22:6, omega-3) acid in the Na+/K+-ATPase preparations from the rat and mouse compared to ouabain-sensitive species. Despite these differences, all animals had similar proportions of total saturated (sigma SAT) and total unsaturated (sigma Unsat) fatty acids. On the other hand, a good correlation between the unsaturation index of membrane lipids and I50 value for ouabain was observed. It is proposed that acyl chain characteristics (unsaturation and/or chain length) rather than the head group of the phospholipid molecule play a major role in the modulation of Na+/K+-ATPase to inhibition by ouabain.

Separation of aerobic glycolysis from oxidative metabolism and contractility in rat anococcygeus muscle

The relationship of aerobic glycolysis (JLac) and O2 utilization (JO2) to contractility and the activity of the Na+-K+ pump was investigated in rat anococcygeus smooth muscle. Removal of extracellular potassium concentration ([K+]o) caused an initial increase followed by a decrease in JLac below the resting rate. Restoration of [K+]o caused JLac to increase, and this response, but not the initial one observed in zero [K+]o, was prevented by ouabain. These changes in JLac were not related to contractility, since a similar response was observed in both phentolamine-treated and chemically denervated muscles that exhibited minimal force and no significant changes in JO2. Tension development of innervated muscles incubated in K+-free medium was related to changes in JO2. A logarithmic relationship between JLac and [K+]o suggested that changes in JLac resulted from effects on glucose transport or utilization secondary to changes in the membrane potential. In stimulated muscles JLac and JO2 were both positively correlated with isometric force and were not affected by ouabain. Separation of JLac from JO2 and force production under some conditions supports the hypothesis that a functional compartmentalization of metabolic pathways exists in anococcygeus muscle.

Extracellular versus intracellular digoxin action on bovine myocardium, using a digoxin antibody and intracellular glycoside application

1. The actions of externally and internally applied digoxin in heart ventricular muscle have been compared. 2. External application of digoxin (5 x 10(-8)--10(-7) M) had an inotropic effect, a steady level of twitch tension being reached at the end of about 3 hr. 3. Addition of an anti-digoxin antibody to the bathing solution prevented or reversed the digoxin effect, depending on the time of application. 4. The efflux of the antibody-[3H]digoxin-complex could be fitted by a single exponential with a half-time of 18 min. 5. In the absence of antibody, [3H]digoxin washout was two-compartmental with half-times of 4 and 72 min respectively. It is thought that the fast process signifies efflux from the extracellular space while the slow process reflects the washout of initially membrane bound glycoside. 6. When digoxin was applied by a cut end method, there was no effect on contractile strength. 7. The profile of radioactivity several hours following exposure to [3H]digoxin clearly indicated movement from cell to cell, the concentration of [3H]digoxin being above 10(-7) M in half the preparation at the end of 6 hr. Longitudinal diffusivity averaged 8.6 x 10(-8) cm-2 sec-1. 8. We conclude that digoxin has an inotropic effect when reaching the surface membrane of cardiac cells from the outside but is ineffective when applied from the inside.

Relation between intracellular Na ion activity and tension of sheep cardiac Purkinje fibers exposed to dihydro-ouabain

The intracellular Na ion activity (aiNa) and the contractile tension (T) of sheep cardiac Purkinje fibers were simultaneously measured employing recessed-tip Na+-selective glass microelectrodes and a mechano-electric transducer. The aiNa of 6.4 +/- 1.6 mM (mean +/- SD, n = 56) was obtained in fibers perfused with normal Tyrode's solution. The changes in aiNa and T were measured during and after the exposure of fibers to a cardiac glycoside, dihydro-ouabain (DHO) in concentrations between 5 X 10(-8) M and 10(-5) M. The exposure time to DHO was 15 min. Both aiNa and T did not change in fibers exposed to 5 X 10(-8) M DHO, and the threshold concentration for the effect of DHO appeared to be around 10(-7) M. In DHO concentrations greater than the threshold, the increases in aiNa and T strongly correlated during the onset of DHO effects. The recoveries of aiNa and T were variable and slow, being dependent on the DHO concentration. In those fibers which recovered from the effects of DHO, the time-course of aiNa recovery was similar to that of T recovery. In fibers exposed to DHO of 5 X 10(-6) M or greater, the apparent toxic effects were observed in both action potential and contraction after an initial increase in T. The fibers manifesting the apparent toxic effects has a aiNa of approximately 30 mM or greater. The results of this study indicate that the increase in aiNa is associated with the positive inotropic action of the cardiac glycoside.

Inhibition by digoxin and SC4453 of (Na+ + K+)-ATPase prepared from human heart, guinea-pig heart and guinea-pig brain

SC4453 is a digoxin analogue with a pyridazine instead of a lactone ring on C17 beta. SC4453 was compared with digoxin with respect to inhibition of (Na+ + K+)-ATPase prepared from human heart, guinea-pig heart and guinea-pig brain. SC4453 was slightly less potent than digoxin but showed a similar sensitivity to K+. As for cardenolides, species differences in sensitivity to SC4453 were accounted for by differences in the rate of dissociation from the receptors. These observations confirm that the human heart is one of the tissues most sensitive to cardiac glycosides.

Sodium ions and the development of the inotropic action of ouabain in guinea-pig heart

Factors that determine the interaction of ouabain with the positive inotropic receptor were examined in isolated perfused guinea-pig hearts. The hearts were exposed to ouabain during a perfusion with a modified Krebs-Henseleit solution. The interaction of ouabain with the inotropic receptors under those conditions was estimated by subsequently perfusing the heart with a regular Krebs-Henseleit solution and monitoring the resting and developed tension. Ouabain failed to cause an increase in the force of contraction when the cardiac tissue was exposed to this agent in the absence of Na+ and Ca2+ either in the presence of a low or high concentration of K+. The absence of Ca2+ or the lack of contraction was not responsible for the failure of ouabain to interact with the inotropic receptor, since the exposure of cardiac tissue to ouabain in a Ca,+-free medium containing Na+ resulted in a development of the positive inotropic effect. Thus, ouabain does not interact with its inotropic receptor in the absence of Na+. The properties of the ouabain-receptor interaction resemble those of ouabain binding to Na+, K+-ATPase. In addition, ouabain increases the mobility of superficially bound Ca2+.

Saturable adenosine 5'-triphosphate-independent binding of [3H]-ouabain to brain and cardiac tissue in vitro

1. Several investigators have proposed that membrane Na+, K+-adenosine 5'-triphosphatase (Na+, K+-ATPase) is a mechanism for the transmembrane transport of cardiac glycosides, rather than the receptor for pharmacological actions of these agents. This implies that the glycosides bind to an intracellular constituent (receptor) other than Na+, K+-ATPase. 2. In search for such a receptor site, saturable ATP-independent [3H]-ouabain binding was studied in rat brain and dog and guinea-pig heart homogenates. The binding of the glucoside to this site results in a relatively unstable complex which is stabilized by K+ to a lesser extent than is the complex formed with the ATP-dependent binding to Na+, K+-ATPase. 3. The ATP-independent ouabain binding sites are more abundant in rat brain tissue than in cardiac tissue, and have a lower ouabain affinity compared to the binding sites on Na+, K+-ATPase. 4. These results do not support the contention that there are intracellular inotropic receptors for digitalis.

Effect of arrhythmogenic doses of deslanoside on the uptake of monoamines in brain tissue and in cardiac tissue

The purpose of our study was to determine whether a toxic arrhythmogenic dose of digitalis administered to an in vivo preparation would affect the neuronal uptake of norepinephrine, serotonin and dopamine in brain tissue and norepinephrine in cardiac tissue. This was investigated by intoxicating anesthetized cats with deslanoside, removing cardiac and brain tissue at the onset of ventricular fibrillation, and examining the ability of brain tissue to accumulate [3H]-NE, [3H]-T-HT and [3H]-DA and cardiac tissue to accumulate [3H]-NE. It was found that deslanoside inhibited uptake of [3H]-NE into the left ventricle and [3H]5-HT into the area postrema. These selective effects may reflect greater blood flow to these regions or different sensitivities of the transport mechanisms for these amines. This inhibition of uptake into both left ventricular tissue and area postrema may contribute to some of the cardiovascular and emetic effects seen with digitalis drugs.

Reduction of the equilibrium binding of cardiac glycosides and related compounds to Na+,K+-ATPase as a possible mechanism for the potassium-induced reversal of their toxicity

The influence of potassium ions on the equilibrium state of the binding of cardiac glycosides and their derivatives to partially purified dog heart and rat brain enzyme preparations was studied in vitro. The addition of potassium to the incubation mixture containing enzyme preparation, 3H-ouabain, Na+, Mg2+ and ATP, at the time when the binding reaction is close to equilibrium, caused an immediate reduction of the bound drug concentration; the concentration apparently shifting toward a lower equilibrium state. The degree of the potassium-induced reduction in bound drug concentration was dependent on the potassium concentration and on the chemical structure of the compound. The binding of aglycones, pentacetyl-gitoxin and cassaine was affected to a greater extent than that of the glycosides. These data suggest that one of the mechanisms by which potassium antagonizes the toxic actions of digitalis on the heart is to reduce the drug binding to cardiac Na+,K+-ATPase.

Correlation between inhibition of (Na+, K+)-membrane-ATPase and positive inotropic activity of cardenolides in isolated papillary muscles of guinea pig

Concentrations of 17 cardenolides, cardenolide glucuronides and sulfates producing half-maximal inhibition of (Na+, K+)-membrane-ATPase from different organs and animal species were determined in vitro. In addition the concentrations that increased the contractility of guinea pig isolated papillary muscles to a particular level were investigated. Comparisons between ATPase-inhibiting and positive inotropic cardiac activities showed extensive parallelism: the correlation coefficients after log/log transformation were between 0.92 and 0.97. The same close correlations are found if dissociation constants of cardenolide receptor complexes and concentrations causing 86Rb-uptake inhibition in human erythrocytes are examined. The concentrations necessary for inhibition of (Na+, K+)-membrane-ATPase of the guinea pig heart and the concentrations required to achieve a defined positive inotropic effect in guinea pig papillary muscle showed a log/log correlation coefficient of 0.97 (P less than 0.001). In both tests the potencies covered more than three orders of magnitude. The results support Repke's hypothesis on the digitalis receptor.

Membrane (Na+ + K+)-ATPase of canine brain, heart and kidney. Tissue-dependent differences in kinetic properties and the influence of purification procedures

Effects of commonly used purification procedures on the yield and specific activity of (Na+ + K+)-ATPase (Mg2+-dependent, Na+ + K+-activated ATP phosphohydrolase, EC 3.6.1.3), the turnover number of the enzyme, and the kinetic parameters for the ATP-dependent ouabain-enzyme interaction were compared in canine brain, heart and kidney. Kinetic parameters were estimated using a graphical analysis of non-steady state kinetics. The protein recovery and the degree of increase in specific activity of (Na+ + K+)-ATPase and the ratio between (Na+ + K+)-ATPase and Mg2+-ATPase activities during the successive treatments with deoxycholate, sodium iodide and glycerol were dependent on the source of the enzyme. A method which yields highly active (Na+ + K+)-ATPase preparations from the cardiac tissue was not suitable for obtaining highly active enzyme preparations from other tissues. Apparent turnover numbers of the brain (Na+ + K+)-ATPase preparations were not significantly affected by the sodium iodide treatment, but markedly decreased by deoxycholate or glycerol treatments. Similar glycerol treatment, however, failed to affect the apparent turnover number of cardiac enzymes preparations. Cerebral and cardiac enzyme preparations obtained by deoxycholate, sodium iodide and glycerol treatments had lower affinity for ouabain than renal enzyme preparations, primarily due to higher dissociation rate constants for the ouabain.enzyme complex. This tissue-dependent difference in ouabain sensitivity seems to be an artifact of the purification procedure, since less purified cerebral or cardiac preparations had lower dissociation rate constants. Changes in apparent association rate constants were minimal during the purfication procedure. These results indicate that the presentyl used purification procedures may alter the properties of membrane (Na+ + K+)-ATPase and affect the interaction between cardiac glycosides and the enzyme. The effect of a given treatment depends on the source of the enzyme. For the in vitro studies involving purified (Na+ + K+)-ATPase preparations, the influence of the methods used to obtain the enzyme preparation should be carefully evaluated.

Membrane adenosinetriphosphatase: a digitalis receptor?

The enzyme Na+,K+-ATPase is a good model for receptor studies because of its known functional correlates. The binding of digitalis to the enzyme observed in vitro satisfied the criteria for receptor binding. Studies of the relationship between the digitalis binding and the drug action reveal an impressive correlation between these events but fail to provide proof of a causal relationship. Studies with other Na+,K+-ATPase inhibitors and agents that affect transmembrane Na+ movements (steps that would follow Na+,K+-ATPase inhibition) provide further supportive evidence that sodium pump inhibition and the resulting enhancement of intracellular Na+ transients cause the inotropic action of digitalis.

[Cardiac effects of antikaliuretic diuretics-clinical and biochemical investigation (author's transl)]

Recently direct myocardial effects of antikaliuretic diuretics with respect to contractility parameters and prevention of digitalis-induced arrhythmias were published. In order to test the value of these reports we measured the effect of potassium-canrenoate and triamterene on cardiac output and on digitalis-induced arrhythmias in patients during diagnostic and the therapeutic flow directed right heart catheterization (Swan-Ganz) in our intensive care unit. In addition the influence of these drugs on (Na+ + K+)-ATPase and on (3H)g-strophanthin binding to human cardiac cell membranes was investigated to gain information on the mechanism of their action. Triamterene (100-200 mg p.o.) was without any effect on cardiac output, the same was found true for potassium-canrenoate given in a single dose (200-1000 mg intravenously). However, when applied in two doses (200 mg i.v. and 60 min later 400 mg i.v.), potassium-canrenoate increased cardiac output by 11 percent (p less than 0.05). Only in 2 out of 14 patients potassium-canrenoate (200-400 mg i.v.) suppressed digitalis-induced ventricular ectopic beats. Canrenone, the active metabolite of potassium-canrenoate displaces [(3H)]g-strophanthin from its binding sites in human cardiac cell membranes and inhibits (Na+ + K+)-ATPase activity. These in vitro effects were measured at the same concentrations as found in vivo after "therapeutical" doses. The effects of triamterene in this respect were found only in extremely high concentrations. Our results imply that canrenone has cardiac glycoside-like effects in human cardiac cell membranes.

The relationship between Na+, K+-ATPase inhibition and cardiac glycoside-induced arrhythmia in dogs

In order to determine if there is a relationship between Na+, K+-ATPase inhibition and cardiac glycoside-induced arrhythmia, the time course of the onset and offset of the arrhythmia induced by the semi-synthetic glycoside, actodigin, and the enzyme activity during arrhythmia and following reversion to normal sinus rhythm was studied in the intact, anethetized dog. An infusion of actodigin(AY22,241) at the rate of 0.1 micronmol/kg/min for 30 min induced a severe and persistent arrhythmia within 13.1 +/- 192 min of 9 dogs. Upon termination of the actodigin infusion, the arrhythmia spontaneously converted to sinus rhythm within 17.5 +/- 2.3 min. Left ventricular tissue was taken from dogs sacrificed at the peak of the actodigin-induced arrhythmic periods or from the dogs that were allowed to recover from the actodigin-induced arrhythmia. These samples were homogenized and the membrane-containing fraction was passed through a Millipore filter. The membrane fraction trapped in the filter was then assayed for Na+ + K+ stimulated, Mg2+ dependent ATPase acctivity. The results showed that, in comparison to the time matched control dogs, the cardiac microsomes prepared from the arrhythmic dogs had a markedly reduced Na+, K+-ATPase activity. On the other hand, actodigin-treated dogs that were allowed to recover from the arrhythmic episode had Na+, K+-ATPase activity that was not significantly different from the control values. The amount of 3H-actodigin bound by the cardiac muscle microsomal fraction was also investigated. The microsomes from left ventricle were isolated with a slight modification of the method of Dutta et al. (1968). The microsomal binding of 3H-actodigin was maximum at 30 min (26.6 mol/mg protein) when the sample was prepared from the dogs at the peak of the arrhythmic effect. However, the binding was significantly reduced (11.5pmol/mg protein) in the microsomal fraction from hearts that had returned to sinus rhythm. These data provide direct evidence that inhibition of Na+, K+-ATPase and cardiac glycosideinduced arrhythmia may have some cause and effect relationship.

Ouabain-receptor interactions in (Na+ + K+)-ATPase preparations. A contribution to the problem of nonlinear Scatchard plots

Specific [3H]ouabain binding to rat and guinea pig skeletal muscle (musculus soleus) was studied using a rapid centrifugation and a filtration method. Both assays gave identical results: the incubation of the cell membranes in 50 mM imidazole/HCl buffer pH 7.25 or 7.4 MgCl2, Pi caused a time dependent loss of (Na+ +K+)-ATPase activity indicating an alteration of the membrane preparation. Ouabain binding properties were changed concomitantly. If ouabain binding was allowed to proceed until equilibrium was reached (3 min in rat and 10 min in guinea pig) at 37 degrees C the data plotted according to Scatchard followed a straight line. The dissociation constants of the ouabain-receptor-complexes of the rat cell membrane preparation as calculated from the slope of the plot (KD = 134 nM) and from the ratio of the dissociation and association rate constants (KD = 175 nM) agreed within experimental error with that determined by Clausen and Hansen [(1974) Biochim. Biophys. Acta 345, 387-404] in intact soleus muscles (KD = 210 nM). If ouabain binding was allowed to proceed for a longer period, however, nonlinear Scatchard plots resulted with an identical maximal number of binding sites but inconstant and decreased affinity for the cardiac glycoside. Experimental evidence is presented that nonlinear Scatchard plots often obtained in hormone (drug)-receptor binding experiments may (among other things) be the result of damaged cell membrane particles in vitro.

An analysis of the actions of low concentrations of ouabain on membrane currents in Purkinje fibres

1. The influence of low concentrations (5 X 10(-8) to 5 X 10(-7) M) of ouabain on the K gradient in sheep cardiac Purkinje fibres was observed by measuring changes in the reversal potential for a K specific current iK2, and by measuring total steady-state current-voltage relations. 2. Provided that the bathing solution K concentration, [K]o was not too low, these doses of ouabain were often observed to increase the K gradient, i.e. the reversal potential was shifted in a negative direction. 3. The change in the reversal potential and in the current-voltage relation could be mimicked by reducing the value of [K]o in the absence of ouabain. It is therefore suggested that ouabain may stimulate the Na+-K+ exchange pump and so reduce the K concentration, [K]e, in the clefts of the preparation. 4. At sufficiently low values of [K]o, a dose of ouabain that was stimulatory may become inhibitory. The reversal potential for iK2 then shifts in a positive direction. 5. During either stimulation or inhibition, the speed of change of reversal potential is consistent with a change in [K]e, which may change fairly rapidly. It is not possible to account for the results solely by changes in intracellular concentration, [K]i. 6. Low concentrations of ouabain were found to have no effect on the activation curve, s infinity (Em), controlling iK2. It is concluded that the changes in iK2 are solely attributable to changes in reversal potential. 7. Since net stimulation of the Na+-K+ exchange pump was observed to occur at doses of ouabain that exert a strong positive inotropic action on Purkinje fibres (Blood, 1975), it is not likely that the inotropic action is causally related to net pump inhibition.