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Xiao Y, Zhang S, Ren Q. The New Orientation of Postoperative Analgesia: Remote Ischemic Preconditioning. J Pain Res 2024; 17:1145-1152. [PMID: 38524690 PMCID: PMC10959302 DOI: 10.2147/jpr.s455127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/13/2024] [Indexed: 03/26/2024] Open
Abstract
Purpose of Review Postoperative analgesia is currently a significant topic in anesthesiology. Currently, the predominant approach for achieving multimodal analgesia involves the utilization of pharmacotherapy and regional anesthesia procedures. The primary objectives of this approach are to mitigate postoperative pain, enhance patient satisfaction, and diminish overall opioid usage. Nevertheless, there is a scarcity of research on the use of remote ischemia preconditioning aimed at mitigating postoperative pain. Recent Findings Transient stoppage of blood flow to an organ has been found to elicit remote ischemia preconditioning (RIPC), which serves as a potent intrinsic mechanism for protecting numerous organs. In addition to its established role in protecting against reperfusion injury, RIPC has recently been identified as having potential benefits in the context of postoperative analgesia. Summary In addition to traditional perioperative analgesia, RIPC provides perioperative analgesia and organ protection.
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Affiliation(s)
- Yunyu Xiao
- Department of Anesthesiology, Hangzhou Ninth People’s Hospital, Hangzhou, Zhejiang, 311225, People’s Republic of China
| | - Shaofeng Zhang
- Department of Anesthesiology, Hangzhou Ninth People’s Hospital, Hangzhou, Zhejiang, 311225, People’s Republic of China
| | - Qiusheng Ren
- Department of Anesthesiology, Hangzhou Ninth People’s Hospital, Hangzhou, Zhejiang, 311225, People’s Republic of China
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2
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Baranova K, Nalivaeva N, Rybnikova E. Neuroadaptive Biochemical Mechanisms of Remote Ischemic Conditioning. Int J Mol Sci 2023; 24:17032. [PMID: 38069355 PMCID: PMC10707673 DOI: 10.3390/ijms242317032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 12/18/2023] Open
Abstract
This review summarizes the currently known biochemical neuroadaptive mechanisms of remote ischemic conditioning. In particular, it focuses on the significance of the pro-adaptive effects of remote ischemic conditioning which allow for the prevention of the neurological and cognitive impairments associated with hippocampal dysregulation after brain damage. The neuroimmunohumoral pathway transmitting a conditioning stimulus, as well as the molecular basis of the early and delayed phases of neuroprotection, including anti-apoptotic, anti-oxidant, and anti-inflammatory components, are also outlined. Based on the close interplay between the effects of ischemia, especially those mediated by interaction of hypoxia-inducible factors (HIFs) and steroid hormones, the involvement of the hypothalamic-pituitary-adrenocortical system in remote ischemic conditioning is also discussed.
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Affiliation(s)
| | | | - Elena Rybnikova
- I. P. Pavlov Institute of Physiology, Russian Academy of Sciences, 199034 Saint Petersburg, Russia; (K.B.); (N.N.)
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3
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Kirschner A, Koch SE, Robbins N, Karthik F, Mudigonda P, Ramasubramanian R, Nieman ML, Lorenz JN, Rubinstein J. Pharmacologic Inhibition of Pain Response to Incomplete Vascular Occlusion Blunts Cardiovascular Preconditioning Response. Cardiovasc Toxicol 2021; 21:889-900. [PMID: 34324134 DOI: 10.1007/s12012-021-09680-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/22/2021] [Indexed: 12/01/2022]
Abstract
Complete vascular occlusion to distant tissue prior to an ischemic cardiac event can provide significant cardioprotection via remote ischemic preconditioning (RIPC). Despite understanding its mechanistic basis, its translation to clinical practice has been unsuccessful, likely secondary to the inherent impossibility of predicting (and therefore preconditioning) an ischemic event, as well as the discomfort that is associated with traditional, fully occlusive RIPC stimuli. Our laboratory has previously shown that non-occlusive banding (NOB) via wrapping of a leather band (similar to a traditional Jewish ritual) can elicit an RIPC response in healthy human subjects. This study sought to further the pain-mediated aspect of this observation in a mouse model of NOB with healthy mice that were exposed to treatment with and without lidocaine to inhibit pain sensation prior to ischemia/reperfusion injury. We demonstrated that NOB downregulates key inflammatory markers resulting in a preconditioning response that is partially mediated via pain sensation.
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Affiliation(s)
- Akiva Kirschner
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sheryl E Koch
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Nathan Robbins
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, USA
| | - Felix Karthik
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Parvathi Mudigonda
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Ranjani Ramasubramanian
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michelle L Nieman
- Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - John N Lorenz
- Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jack Rubinstein
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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4
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Hausenloy DJ, Bøtker HE, Ferdinandy P, Heusch G, Ng GA, Redington A, Garcia-Dorado D. Cardiac innervation in acute myocardial ischaemia/reperfusion injury and cardioprotection. Cardiovasc Res 2020; 115:1167-1177. [PMID: 30796814 DOI: 10.1093/cvr/cvz053] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 12/21/2018] [Accepted: 02/21/2019] [Indexed: 12/13/2022] Open
Abstract
Acute myocardial infarction (AMI) and the heart failure (HF) that often complicates this condition, are among the leading causes of death and disability worldwide. To reduce myocardial infarct (MI) size and prevent heart failure, novel therapies are required to protect the heart against the detrimental effects of acute ischaemia/reperfusion injury (IRI). In this regard, targeting cardiac innervation may provide a novel therapeutic strategy for cardioprotection. A number of cardiac neural pathways mediate the beneficial effects of cardioprotective strategies such as ischaemic preconditioning and remote ischaemic conditioning, and nerve stimulation may therefore provide a novel therapeutic strategy for cardioprotection. In this article, we provide an overview of cardiac innervation and its impact on acute myocardial IRI, the role of extrinsic and intrinsic cardiac neural pathways in cardioprotection, and highlight peripheral and central nerve stimulation as a cardioprotective strategy with therapeutic potential for reducing MI size and preventing HF following AMI. This article is part of a Cardiovascular Research Spotlight Issue entitled 'Cardioprotection Beyond the Cardiomyocyte', and emerged as part of the discussions of the European Union (EU)-CARDIOPROTECTION Cooperation in Science and Technology (COST) Action, CA16225.
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Affiliation(s)
- Derek J Hausenloy
- Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore.,National Heart Research Institute Singapore, National Heart Centre, Singapore.,Yong Loo Lin School of Medicine, National University Singapore, Singapore.,The Hatter Cardiovascular Institute, University College London, London, UK.,The National Institute of Health Research University College London Hospitals Biomedical Research Centre, Research & Development, London, UK.,Tecnologico de Monterrey, Centro de Biotecnologia-FEMSA, Nuevo Leon, Mexico
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Peter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary.,Pharmahungary Group, Szeged, Hungary
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Essen, Germany
| | - G André Ng
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, UK
| | - Andrew Redington
- Cincinnati Children's Hospital Medical Center, Heart Institute, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David Garcia-Dorado
- Department of Cardiology, Vascular Biology and Metabolism Area, Vall d'Hebron University Hospital and Research Institute (VHIR), Universitat Autónoma de Barcelona, Spain.,Instituto CIBER de Enfermedades Cardiovasculares (CIBERCV): Instituto de Salud Carlos III, Madrid, Spain
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5
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Ederer I, Goertz O, Bosselmann T, Sogorski A, Zahn P, Lehnhardt M, Daigeler A, Kolbenschlag J. Anesthesia of the conditioned limb does not abolish the remote ischemic conditioning stimulus on cutaneous microcirculation in humans. Clin Hemorheol Microcirc 2020; 74:155-166. [DOI: 10.3233/ch-190626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- I.A. Ederer
- Department of Hand, Plastic and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - O. Goertz
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - T. Bosselmann
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - A. Sogorski
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - P.K. Zahn
- Department of Anesthesiology and Intensive Care Medicine, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - M. Lehnhardt
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - A. Daigeler
- Department of Hand, Plastic and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - J. Kolbenschlag
- Department of Hand, Plastic and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
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6
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Chen K, Yu J, Wang Q, Wu L, Liu X, Wong GTC, Lu Y. The timing of propofol administration affects the effectiveness of remote ischemic preconditioning induced cardioprotection in rats. J Cell Biochem 2020; 121:4535-4541. [PMID: 32030809 DOI: 10.1002/jcb.29671] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 01/16/2020] [Indexed: 12/18/2022]
Abstract
The cardioprotection of remote ischemic preconditioning (RIPC) is abolished under propofol maintained anesthesia. Transient receptor potential vanilloid 1 (TRPV1) channel is present in the heart, and its activation could induce cardioprotection. Therefore, we tested whether the anesthetic propofol administration phase interfered with the RIPC-induced cardioprotection, and RIPC-induced cardioprotection via the cardiac TRPV1 channel. Male Sprague-Dawley rats were subjected to myocardial 30 minutes of ischemia followed by 2 hours of reperfusion. RIPC consisted of three cycles of 5-minute ischemia/reperfusion applied to a hindlimb. Propofol infusion at 12 mg/kg/h was commenced either at 10 minutes before the start of RIPC in the P-pre + RIPC group, or immediately after myocardial ischemia at the onset of reperfusion (P-post + RIPC) while performing RIPC. These two propofol infusion regimes were applied to another two grou bs without RIPC (P-pre and P-post groups). Infarct size (IS) was assessed by triphenyltetrazolium staining. Heart TRPV1 expression was detected by Western blot and immunofluorescence. RIPC significantly reduced myocardial IS compared with the control group (36.7 ± 3% versus 57.2 ± 4%; P < .01). When propofol was started before RIPC, the IS sparing effect of RIPC was completely abolished. However, propofol infusion starting immediately after myocardial ischemia did not affect RIPC-induced cardioprotection. TRPV1 expression significant increase after RIPC, then propofol inhibited the TRPV1 activation of RIPC if given before RIPC but not after. Our results suggest that the timing of propofol administration is critical to preserve the cardioprotection of RIPC. Propofol might cancel RIPC-induced cardioprotection via the cardiac TRPV1 receptor.
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Affiliation(s)
- Ke Chen
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Junma Yu
- Hefei National Laboratory for Physical Sciences at the Microscale, Department of Biophysics and Neurobiology, University of Science and Technology of China, Hefei, China.,Department of Anesthesiology, The Third Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Qiuyue Wang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Lining Wu
- Hefei National Laboratory for Physical Sciences at the Microscale, Department of Biophysics and Neurobiology, University of Science and Technology of China, Hefei, China
| | - Xuesheng Liu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | | | - Yao Lu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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7
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Lau JK, Roy P, Javadzadegan A, Moshfegh A, Fearon WF, Ng M, Lowe H, Brieger D, Kritharides L, Yong AS. Remote Ischemic Preconditioning Acutely Improves Coronary Microcirculatory Function. J Am Heart Assoc 2019; 7:e009058. [PMID: 30371329 PMCID: PMC6404904 DOI: 10.1161/jaha.118.009058] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Remote ischemic preconditioning (RIPC) attenuates myocardial damage during elective and primary percutaneous coronary intervention. Recent studies suggest that coronary microcirculatory function is an important determinant of clinical outcome. The aim of this study was to assess the effect of RIPC on markers of microcirculatory function. Methods and Results Patients referred for cardiac catheterization and fractional flow reserve measurement were randomized to RIPC or sham. Operators and patients were blinded to treatment allocation. Comprehensive physiological assessments were performed before and after RIPC/sham including the index of microcirculatory resistance and coronary flow reserve after intracoronary glyceryl trinitrate and during the infusion of intravenous adenosine. Thirty patients were included (87% male; mean age: 63.1±10.0 years). RIPC and sham groups were similar with respect to baseline characteristics. RIPC decreased the calculated index of microcirculatory resistance (median, before RIPC: 22.6 [interquartile range [IQR]: 17.9-25.6]; after RIPC: 17.5 [IQR: 14.5-21.3]; P=0.007) and increased coronary flow reserve (2.6±0.9 versus 3.8±1.7, P=0.001). These RIPC-mediated changes were associated with a reduction in hyperemic transit time (median: 0.33 [IQR: 0.26-0.40] versus 0.25 [IQR: 0.20-0.30]; P=0.010). RIPC resulted in a significant decrease in the calculated index of microcirculatory resistance compared with sham (relative change with treatment [mean±SD] was -18.1±24.8% versus +6.1±37.5; P=0.047) and a significant increase in coronary flow reserve (+41.2% [IQR: 20.0-61.7] versus -7.8% [IQR: -19.1 to 10.3]; P<0.001). Conclusions The index of microcirculatory resistance and coronary flow reserve are acutely improved by remote ischemic preconditioning. This raises the possibility that RIPC confers cardioprotection during percutaneous coronary intervention as a result of an improvement in coronary microcirculatory function. Clinical Trial Registration URL: www.anzctr.org.au/ . Unique identifier: CTRN12616000486426.
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Affiliation(s)
- Jerrett K Lau
- 1 Concord Repatriation General Hospital University of Sydney Australia.,2 ANZAC Research Institute University of Sydney Australia
| | - Probal Roy
- 1 Concord Repatriation General Hospital University of Sydney Australia
| | - Ashkan Javadzadegan
- 2 ANZAC Research Institute University of Sydney Australia.,4 Faculty of Medicine and Health Sciences Macquarie University Sydney Australia
| | - Abouzar Moshfegh
- 2 ANZAC Research Institute University of Sydney Australia.,4 Faculty of Medicine and Health Sciences Macquarie University Sydney Australia
| | - William F Fearon
- 5 Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA
| | - Martin Ng
- 3 Department of Cardiology Royal Prince Alfred Hospital University of Sydney Australia
| | - Harry Lowe
- 1 Concord Repatriation General Hospital University of Sydney Australia
| | - David Brieger
- 1 Concord Repatriation General Hospital University of Sydney Australia.,2 ANZAC Research Institute University of Sydney Australia
| | - Leonard Kritharides
- 1 Concord Repatriation General Hospital University of Sydney Australia.,2 ANZAC Research Institute University of Sydney Australia
| | - Andy S Yong
- 1 Concord Repatriation General Hospital University of Sydney Australia.,2 ANZAC Research Institute University of Sydney Australia.,4 Faculty of Medicine and Health Sciences Macquarie University Sydney Australia
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8
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Zhou D, Ding J, Ya J, Pan L, Wang Y, Ji X, Meng R. Remote ischemic conditioning: a promising therapeutic intervention for multi-organ protection. Aging (Albany NY) 2019; 10:1825-1855. [PMID: 30115811 PMCID: PMC6128414 DOI: 10.18632/aging.101527] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 08/10/2018] [Indexed: 12/21/2022]
Abstract
Despite decades of formidable exploration, multi-organ ischemia-reperfusion injury (IRI) encountered, particularly amongst elderly patients with clinical scenarios, such as age-related arteriosclerotic vascular disease, heart surgery and organ transplantation, is still an unsettled conundrum that besets clinicians. Remote ischemic conditioning (RIC), delivered via transient, repetitive noninvasive IR interventions to distant organs or tissues, is regarded as an innovative approach against IRI. Based on the available evidence, RIC holds the potential of affording protection to multiple organs or tissues, which include not only the heart and brain, but also others that are likely susceptible to IRI, such as the kidney, lung, liver and skin. Neuronal and humoral signaling pathways appear to play requisite roles in the mechanisms of RIC-related beneficial effects, and these pathways also display inseparable interactions with each other. So far, several hurdles lying ahead of clinical translation that remain to be settled, such as establishment of biomarkers, modification of RIC regimen, and deep understanding of underlying minutiae through which RIC exerts its powerful function. As this approach has garnered an increasing interest, herein, we aim to encapsulate an overview of the basic concept and postulated protective mechanisms of RIC, highlight the main findings from proof-of-concept clinical studies in various clinical scenarios, and also to discuss potential obstacles that remain to be conquered. More well designed and comprehensive experimental work or clinical trials are warranted in future research to confirm whether RIC could be utilized as a non-invasive, inexpensive and efficient adjunct therapeutic intervention method for multi-organ protection.
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Affiliation(s)
- Da Zhou
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Jiayue Ding
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Jingyuan Ya
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Liqun Pan
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Yuan Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Ran Meng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
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9
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Noronha Osório D, Viana-Soares R, Marto JP, Mendonça MD, Silva HP, Quaresma C, Viana-Baptista M, Gamboa H, Vieira HLA. Autonomic nervous system response to remote ischemic conditioning: heart rate variability assessment. BMC Cardiovasc Disord 2019; 19:211. [PMID: 31500561 PMCID: PMC6734354 DOI: 10.1186/s12872-019-1181-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/12/2019] [Indexed: 11/17/2022] Open
Abstract
Background Remote ischemic conditioning (RIC) is a procedure applied in a limb for triggering endogenous protective pathways in distant organs, namely brain or heart. The underlying mechanisms of RIC are still not fully understood, and it is hypothesized they are mediated either by humoral factors, immune cells and/or the autonomic nervous system. Herein, heart rate variability (HRV) was used to evaluate the electrophysiological processes occurring in the heart during RIC and, in turn to assess the role of autonomic nervous system. Methods Healthy subjects were submitted to RIC protocol and electrocardiography (ECG) was used to evaluate HRV, by assessing the variability of time intervals between two consecutive heart beats. This is a pilot study based on the analysis of 18 ECG from healthy subjects submitted to RIC. HRV was characterized in three domains (time, frequency and non-linear features) that can be correlated with the autonomic nervous system function. Results RIC procedure increased significantly the non-linear parameter SD2, which is associated with long term HRV. This effect was observed in all subjects and in the senior (> 60 years-old) subset analysis. SD2 increase suggests an activation of both parasympathetic and sympathetic nervous system, namely via fast vagal response (parasympathetic) and the slow sympathetic response to the baroreceptors stimulation. Conclusions RIC procedure modulates both parasympathetic and sympathetic autonomic nervous system. Furthermore, this modulation is more pronounced in the senior subset of subjects. Therefore, the autonomic nervous system regulation could be one of the mechanisms for RIC therapeutic effectiveness. Electronic supplementary material The online version of this article (10.1186/s12872-019-1181-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel Noronha Osório
- LIBPhys-UNL - Laboratorio de Instrumentação, Engenharia Biomédica e Física da Radiação (LIBPhys-UNL), Departamento de Física, Faculdade de Ciências e Tecnologia da Universidade Nova de Lisboa, Monte da Caparica, 2892-516, Caparica, Portugal.,PLUX - Wireless Biosignals, S.A, Lisboa, Portugal
| | - Ricardo Viana-Soares
- CEDOC - NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria, 130, 1169-056, Lisboa, Portugal
| | - João Pedro Marto
- CEDOC - NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria, 130, 1169-056, Lisboa, Portugal.,Department of Neurology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Marcelo D Mendonça
- CEDOC - NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria, 130, 1169-056, Lisboa, Portugal.,Department of Neurology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal.,Champalimaud Research, Champalimaud Centre for the Unknown, Lisboa, 7IT - Instituto de Telecomunicações, Lisboa, Portugal
| | - Hugo P Silva
- PLUX - Wireless Biosignals, S.A, Lisboa, Portugal.,EST/IPS - Escola Superior de Tecnologia do Instituto Politécnico de Setúbal, Setúbal, Portugal.,iBET - Instituto de Biologia Experimental e Tecnológica, Oeiras, Portugal
| | - Cláudia Quaresma
- LIBPhys-UNL - Laboratorio de Instrumentação, Engenharia Biomédica e Física da Radiação (LIBPhys-UNL), Departamento de Física, Faculdade de Ciências e Tecnologia da Universidade Nova de Lisboa, Monte da Caparica, 2892-516, Caparica, Portugal
| | - Miguel Viana-Baptista
- CEDOC - NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria, 130, 1169-056, Lisboa, Portugal.,Department of Neurology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Hugo Gamboa
- LIBPhys-UNL - Laboratorio de Instrumentação, Engenharia Biomédica e Física da Radiação (LIBPhys-UNL), Departamento de Física, Faculdade de Ciências e Tecnologia da Universidade Nova de Lisboa, Monte da Caparica, 2892-516, Caparica, Portugal.
| | - Helena L A Vieira
- CEDOC - NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria, 130, 1169-056, Lisboa, Portugal.
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10
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Basalay MV, Davidson SM, Gourine AV, Yellon DM. Neural mechanisms in remote ischaemic conditioning in the heart and brain: mechanistic and translational aspects. Basic Res Cardiol 2018; 113:25. [PMID: 29858664 PMCID: PMC5984640 DOI: 10.1007/s00395-018-0684-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/02/2018] [Accepted: 05/23/2018] [Indexed: 12/13/2022]
Abstract
Remote ischaemic conditioning (RIC) is a promising method of cardioprotection, with numerous clinical studies having demonstrated its ability to reduce myocardial infarct size and improve prognosis. On the other hand, there are several clinical trials, in particular those conducted in the setting of elective cardiac surgery, that have failed to show any benefit of RIC. These contradictory data indicate that there is insufficient understanding of the mechanisms underlying RIC. RIC is now known to signal indiscriminately, protecting not only the heart, but also other organs. In particular, experimental studies have demonstrated that it is able to reduce infarct size in an acute ischaemic stroke model. However, the mechanisms underlying RIC-induced neuroprotection are even less well understood than for cardioprotection. The existence of bidirectional feedback interactions between the heart and the brain suggests that the mechanisms of RIC-induced neuroprotection and cardioprotection should be studied as a whole. This review, therefore, addresses the topic of the neural component of the RIC mechanism.
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Affiliation(s)
- Marina V Basalay
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK
| | - Sean M Davidson
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK
| | - Andrey V Gourine
- Department of Cardiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Derek M Yellon
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK.
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Zhang L, Guo H, Yuan F, Hong ZC, Tian YM, Zhang XJ, Zhang Y. Limb remote ischemia per-conditioning protects the heart against ischemia–reperfusion injury through the opioid system in rats. Can J Physiol Pharmacol 2018; 96:68-75. [PMID: 28763627 DOI: 10.1139/cjpp-2016-0585] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Remote ischemia per-conditioning (RPerC) has been demonstrated to have cardiac protection, but the underlying mechanism remains unclear. This study aimed to investigate the mechanism underlying cardiac protection of RPerC. Adult male Sprague–Dawley rats were used in this study. Cardiac ischemia/reperfusion (I/R) was induced by 30 min of occlusion and 3 h of reperfusion of the left anterior descending coronary artery. RPerC were performed by 5 min of occlusion of the right femoral artery followed by 5 min of reperfusion for three times during cardiac ischemia. The hemodynamics, left ventricular function, arrhythmia, and infarct area were measured. Protein expression levels of endothelial nitric oxide synthase (eNOS), inducible NOS (iNOS), protein kinase C-ε (PKCε), and PKCδ in the myocardium were assayed. During I/R, systolic artery pressure and left ventricular function were decreased, infarct area was increased, and arrhythmia score was increased (P < 0.05). However, changes of the above parameters were significantly attenuated in RPerC-treated rats compared with control rats (P < 0.05). The cardiac protective effects of RPerC were prevented by naloxone or glibenclamide. Also, RPerC increased the protein expression levels of eNOS, iNOS, PKCε, and PKCδ in the myocardium compared with control rats. These effects were blocked by naloxone, an opioid receptor antagonist, and glibenclamide, an ATP-sensitive K+ channel blocker (KATP). In summary, this study suggests that RPerC protects the heart against I/R injury through activation of opioid receptors and the NO–PKC–KATP channel signaling pathways.
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Affiliation(s)
- Li Zhang
- Department of Physiology, Hebei Medical University, Shijiazhuang, 050017, P.R. China
- Orthopedic Department of Third Hospital, Hebei Medical University, Shijiazhuang, 050000, P.R. China
| | - Hui Guo
- Department of Gynaecology and Obstetrics, Fourth Hospital, Hebei Medical University, Shijiazhuang 050000, P.R. China
| | - Fang Yuan
- Department of Physiology, Hebei Medical University, Shijiazhuang, 050017, P.R. China
- Hebei Collaborative Innovation Center for Cardio-cerebrovascular Disease, Shijiazhuang 050000, P.R. China
| | - Zeng-chao Hong
- Operation room of Third Hospital, Hebei Medical University, Shijiazhuang, 050000, P.R. China
| | - Yan-ming Tian
- Department of Physiology, Hebei Medical University, Shijiazhuang, 050017, P.R. China
| | - Xiang-jian Zhang
- Hebei Collaborative Innovation Center for Cardio-cerebrovascular Disease, Shijiazhuang 050000, P.R. China
| | - Yi Zhang
- Department of Physiology, Hebei Medical University, Shijiazhuang, 050017, P.R. China
- Hebei Collaborative Innovation Center for Cardio-cerebrovascular Disease, Shijiazhuang 050000, P.R. China
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Youn YJ, Yoo BS, Son JW, Lee JW, Ahn MS, Ahn SG, Kim JY, Lee SH, Yoon J, Eom YW, Oh JE, Choi SK. Remote Ischemic Conditioning by Effluent Collected from a Novel Isolated Hindlimb Model Reduces Infarct Size in an Isolated Heart Model. Korean Circ J 2017; 47:714-726. [PMID: 28955390 PMCID: PMC5614948 DOI: 10.4070/kcj.2017.0092] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 05/16/2017] [Accepted: 05/22/2017] [Indexed: 02/03/2023] Open
Abstract
Background and Objectives Experimental protocols for remote ischemic conditioning (RIC) utilize models in which a tourniquet is placed around the hindlimb or effluent is collected from an isolated heart. In analyzing the humoral factors that act as signal transducers in these models, sampled blood can be influenced by systemic responses, while the effluent from an isolated heart might differ from that of the hindlimb. Thus, we designed a new isolated hindlimb model for RIC and tested whether the effluent from this model could affect ischemia/reperfusion (IR) injury and if the reperfusion injury salvage kinase (RISK) and survivor activating factor enhancement (SAFE) pathways are involved in RIC. Materials and Methods After positioning needles into the right iliac artery and vein of rats, Krebs-Henseleit buffer was perfused using a Langendorff apparatus, and effluent was collected. The RIC protocol consisted of 3 cycles of IR for 5 minutes. In the RIC effluent group, collected effluent was perfused in an isolated heart for 10 minutes before initiating IR injury. Results Compared with the control group, the infarct area in the RIC effluent group was significantly smaller (31.2%±3.8% vs. 20.6%±1.8%, p<0.050), while phosphorylation of signal transducer and activation of transcription-3 (STAT-3) was significantly increased. However, there was a trend of increased phosphorylation of extracellular signal-regulated kinase (ERK) 1/2 in this group. Conclusion This is the first study to investigate the effect of effluent from a new isolated hindlimb model after RIC on IR injury in an isolated heart model. The RIC effluent was effective in reducing the IR injury, and the cardioprotective effect was associated with activation of the SAFE pathway.
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Affiliation(s)
- Young Jin Youn
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Byung-Su Yoo
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jung-Woo Son
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jun-Won Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Min-Soo Ahn
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Gyun Ahn
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jang-Young Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seung-Hwan Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Junghan Yoon
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Woo Eom
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Ji-Eun Oh
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seong-Kyung Choi
- Animal Core, Central Research Laboratory, Yonsei University Wonju College of Medicine, Wonju, Korea
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Lau JK, Pennings GJ, Yong A, Kritharides L. Cardiac Remote Ischaemic Preconditioning: Mechanistic and Clinical Considerations. Heart Lung Circ 2017; 26:545-553. [DOI: 10.1016/j.hlc.2016.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 11/04/2016] [Indexed: 12/15/2022]
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Aulakh AS, Randhawa PK, Singh N, Jaggi AS. Neurogenic pathways in remote ischemic preconditioning induced cardioprotection: Evidences and possible mechanisms. THE KOREAN JOURNAL OF PHYSIOLOGY & PHARMACOLOGY : OFFICIAL JOURNAL OF THE KOREAN PHYSIOLOGICAL SOCIETY AND THE KOREAN SOCIETY OF PHARMACOLOGY 2017; 21:145-152. [PMID: 28280407 PMCID: PMC5343047 DOI: 10.4196/kjpp.2017.21.2.145] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 08/02/2016] [Accepted: 08/18/2016] [Indexed: 11/15/2022]
Abstract
Remote ischemic preconditioning (RIPC) is an intrinsic phenomenon whereby 3~4 consecutive ischemia-reperfusion cycles to a remote tissue (noncardiac) increases the tolerance of the myocardium to sustained ischemiareperfusion induced injury. Remote ischemic preconditioning induces the local release of chemical mediators which activate the sensory nerve endings to convey signals to the brain. The latter consequently stimulates the efferent nerve endings innervating the myocardium to induce cardioprotection. Indeed, RIPC-induced cardioprotective effects are reliant on the presence of intact neuronal pathways, which has been confirmed using nerve resection of nerves including femoral nerve, vagus nerve, and sciatic nerve. The involvement of neurogenic signaling has been further substantiated using various pharmacological modulators including hexamethonium and trimetaphan. The present review focuses on the potential involvement of neurogenic pathways in mediating remote ischemic preconditioning-induced cardioprotection.
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Affiliation(s)
- Amritpal Singh Aulakh
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University Patiala, Patiala 147002, India
| | - Puneet Kaur Randhawa
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University Patiala, Patiala 147002, India
| | - Nirmal Singh
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University Patiala, Patiala 147002, India
| | - Amteshwar Singh Jaggi
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University Patiala, Patiala 147002, India
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15
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Cardioprotection by remote ischemic conditioning and its signal transduction. Pflugers Arch 2016; 469:159-181. [DOI: 10.1007/s00424-016-1922-6] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 11/28/2016] [Indexed: 12/23/2022]
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16
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Adenosine Receptor Activation in the "Trigger" Limb of Remote Pre-Conditioning Mediates Human Endothelial Conditioning and Release of Circulating Cardioprotective Factor(s). JACC Basic Transl Sci 2016; 1:461-471. [PMID: 30167533 PMCID: PMC6113421 DOI: 10.1016/j.jacbts.2016.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 06/09/2016] [Accepted: 06/16/2016] [Indexed: 01/22/2023]
Abstract
Pre-conditioning has emerged as a potentially powerful means of reducing ischemia-reperfusion injury. Several animal models have implicated adenosine in pre-conditioning pathways, but its role in human physiology is unknown. In human volunteers, the authors demonstrate that adenosine receptor activation in “trigger” tissue is an important step in initiating a pre-conditioning signal, but adenosine receptor blockade in “target” tissue does not block the protection afforded by pre-conditioning. The authors also demonstrate that pre-conditioning elaborates a transferrable cardioprotective factor(s) into the serum. This elaboration is prevented by adenosine receptor blockade but can be mirrored by the infusion of exogenous adenosine. An improved understanding of the physiological effectors of pre-conditioning may allow for better targeted clinical studies of pre-conditioning and pre-conditioning mimetics in the future.
Remote ischemic pre-conditioning (rIPC) has emerged as a potential mechanism to reduce ischemia-reperfusion injury. Clinical data, however, have been mixed, and its physiological basis remains unclear, although it appears to involve release of circulating factor(s) and/or neural pathways. Here, the authors demonstrate that adenosine receptor activation is an important step in initiating human pre-conditioning; that pre-conditioning liberates circulating cardioprotective factor(s); and that exogenous adenosine infusion is able to recapitulate release of this factor. However, blockade of adenosine receptors in ischemic tissue does not block the protection afforded by pre-conditioning. These data have important implications for defining the physiology of human pre-conditioning and its translation to future clinical trials.
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Anttila V, Haapanen H, Yannopoulos F, Herajärvi J, Anttila T, Juvonen T. Review of remote ischemic preconditioning: from laboratory studies to clinical trials. SCAND CARDIOVASC J 2016; 50:355-361. [PMID: 27595164 DOI: 10.1080/14017431.2016.1233351] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In remote ischemic preconditioning (RIPC) short periods of non-lethal ischemia followed by reperfusion of tissue or organ prepare remote tissue or organ to resist a subsequent more severe ischemia-reperfusion injury. The signaling mechanism of RIPC can be humoral communication, neuronal stimulation, systemic modification of circulating immune cells, and activation of hypoxia inducible genes. Despite promising evidence from experimental studies, the clinical effects of RIPC have been controversial. Heterogeneity of inclusion and exclusion criteria and confounding factors such as comedication, anesthesia, comorbidities, and other risk factors may have influenced the efficacy of RIPC. Although the cardioprotective pathways of RIPC are more widely studied, there is also evidence of benefits in CNS, kidney and liver protection. Future research should explore the potential of RIPC, not only in cardiac protection, but also in patients with threatening ischemia of the brain, organ transplantation of the heart, liver and kidney and extensive cardiovascular surgery. RIPC is generally well-tolerated, safe, effective, and easily feasible. It has a great prospect for ischemic protection of the heart and other organs.
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Affiliation(s)
- Vesa Anttila
- a Heart Center, Turku University Hospital , Turku , Finland
| | - Henri Haapanen
- b Research Unit of Surgery, Anesthesia and Intensive Care , University of Oulu and MRC Oulu , Oulu , Finland
| | - Fredrik Yannopoulos
- b Research Unit of Surgery, Anesthesia and Intensive Care , University of Oulu and MRC Oulu , Oulu , Finland
| | - Johanna Herajärvi
- b Research Unit of Surgery, Anesthesia and Intensive Care , University of Oulu and MRC Oulu , Oulu , Finland
| | - Tuomas Anttila
- b Research Unit of Surgery, Anesthesia and Intensive Care , University of Oulu and MRC Oulu , Oulu , Finland
| | - Tatu Juvonen
- c Department of Cardiac Surgery , Heart and Lung Center HUCH , Helsinki , Finland
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18
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He SF, Zhu HJ, Han ZY, Wu H, Jin SY, Irwin MG, Zhang Y. MicroRNA-133b-5p Is Involved in Cardioprotection of Morphine Preconditioning in Rat Cardiomyocytes by Targeting Fas. Can J Cardiol 2016; 32:996-1007. [DOI: 10.1016/j.cjca.2015.10.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 10/20/2015] [Accepted: 10/22/2015] [Indexed: 12/11/2022] Open
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Abstract
Remote ischemic preconditioning (RIPC) is an intriguing process whereby transient regional ischemia and reperfusion episodes to remote tissues including skeletal, renal, mesenteric provide protection to the heart against sustained ischemia-reperfusion-induced injury. Clinically, this technique has been used in patients undergoing various surgical interventions including coronary artery bypass graft surgery, abdominal aortic aneurysm repair, percutaneous coronary intervention, and heart valve surgery. The endogenous opioid system is extensively expressed in the brain to modulate pain sensation. Besides the role of opioids in relieving pain, numerous researchers have found their critical involvement in evoking cardioprotective effects. Endogenous opioids including endorphins, enkephalins, and dynorphins are released during RIPC and are critically involved in mediating RIPC-induced cardioprotective effects. It has been suggested that during RIPC, the endogenous opioids may be released into the systemic circulation and may travel via bloodstream that act on the myocardial opioid receptors to induce cardioprotection. The present review describes the potential role of opioids in mediating RIPC-induced cardioprotection.
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Affiliation(s)
- Puneet Kaur Randhawa
- 1 Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Patiala, Punjab, India
| | - Amteshwar Singh Jaggi
- 1 Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Patiala, Punjab, India
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20
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Abstract
OBJECTIVE Acute kidney injury is a common complication in critically ill patients and is associated with increased morbidity and mortality. Sepsis, major surgery, and nephrotoxic drugs are the most common causes of acute kidney injury. There is currently no effective strategy available to prevent or treat acute kidney injury. Therefore, novel treatment regimens are required to decrease acute kidney injury prevalence and to improve clinical outcomes. Remote ischemic preconditioning, triggered by brief episodes of ischemia and reperfusion applied in distant tissues or organs before the injury of the target organ, attempts to invoke adaptive responses that protect against acute kidney injury. We sought to evaluate the clinical evidence for remote ischemic preconditioning as a potential strategy to protect the kidney and to review the underlying mechanisms in light of recent studies. DATA SOURCES We searched PubMed for studies reporting the effect of remote ischemic preconditioning on kidney function in surgical patients (search terms: "remote ischemic preconditioning," "kidney function," and "surgery"). We also reviewed bibliographies of relevant articles to identify additional citations. STUDY SELECTION Published studies, consisting of randomized controlled trials, are reviewed. DATA EXTRACTION The authors used consensus to summarize the evidence behind the use of remote ischemic preconditioning. DATA SYNTHESIS In addition, the authors suggest patient populations and clinical scenarios in which remote ischemic preconditioning might be best applied. CONCLUSIONS Several experimental and clinical studies have shown tissue-protective effects of remote ischemic preconditioning in various target organs, including the kidneys. Remote ischemic preconditioning may offer a novel, noninvasive, and inexpensive treatment strategy for decreasing acute kidney injury prevalence in high-risk patients. Although many new studies have further advanced our knowledge in this area, the appropriate intensity of remote ischemic preconditioning, its mechanisms of action, and the role of biomarkers for patient selection and monitoring are still unknown.
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21
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Johnsen J, Pryds K, Salman R, Løfgren B, Kristiansen SB, Bøtker HE. The remote ischemic preconditioning algorithm: effect of number of cycles, cycle duration and effector organ mass on efficacy of protection. Basic Res Cardiol 2016; 111:10. [DOI: 10.1007/s00395-016-0529-6] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 01/05/2016] [Indexed: 11/29/2022]
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22
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Irwin MG, Wong GTC. Remifentanil and Opioid-Induced Cardioprotection. J Cardiothorac Vasc Anesth 2015; 29 Suppl 1:S23-6. [DOI: 10.1053/j.jvca.2015.01.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Indexed: 02/07/2023]
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23
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Cheng X, Zhang YE, Lu X, Lu Y, Chen Z. The involvement of central beta-endorphin in the cardioprotective effects of remote preconditioning mediated by the intracerebroventricular administration of morphine. Ir J Med Sci 2015; 185:423-31. [PMID: 25971466 DOI: 10.1007/s11845-015-1308-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 05/02/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Opioids can mimic the effects of remote cardiac preconditioning and mediate a subsequent reduction in myocardial infarct size. AIM This study investigated the role of beta-endorphin (β-EP) in intracerebroventricular morphine cardioprotection. METHODS Anesthetized, open-chest, male Sprague-Dawley rats were assigned to 1 of 9 treatment groups 3 days after intracerebroventricular catheter placement. Remote preconditioning was induced with 3 μg/kg of morphine. The β-EP antagonist was administered via intracerebroventricular or intravenous routes either 10 min before or immediately after morphine or saline administration. Ischemia-reperfusion injury was caused by 30 min of left coronary artery occlusion followed by 120 min of reperfusion. The infarct size, as a percentage of the area at risk, was determined by 2,3,5-triphenyltetrazolium staining. Radioimmunoassay and immunoreactivity were used to determine the β-EP levels in the serum and brain. RESULTS Intracerebroventricular administration of β-EP antiserum (AEP) after morphine administration attenuated the cardioprotective effects of remote preconditioning. The addition of intravenous AEP either before or after morphine did not affect infarct size. After morphine preconditioning, the β-EP level decreased in the hypothalamic arcuate nucleus and increased significantly in the serum, pituitary gland, ventrolateral periaqueductal gray and rostral ventrolateral medulla. CONCLUSION Central but not peripheral β-EP is involved in morphine remote preconditioning and plays a role in the ongoing mediation of cardioprotective effects.
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Affiliation(s)
- X Cheng
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Shushan, Hefei, China.
| | - Y E Zhang
- Department of Anesthesiology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - X Lu
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Shushan, Hefei, China
| | - Y Lu
- Department of Anesthesiology, Third Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Z Chen
- Department of Pharmacology, Anhui Medical University, Hefei, China
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Abstract
Reperfusion is mandatory to salvage ischemic myocardium from infarction, but reperfusion per se contributes to injury and ultimate infarct size. Therefore, cardioprotection beyond that by timely reperfusion is needed to reduce infarct size and improve the prognosis of patients with acute myocardial infarction. The conditioning phenomena provide such cardioprotection, insofar as brief episodes of coronary occlusion/reperfusion preceding (ischemic preconditioning) or following (ischemic postconditioning) sustained myocardial ischemia with reperfusion reduce infarct size. Even ischemia/reperfusion in organs remote from the heart provides cardioprotection (remote ischemic conditioning). The present review characterizes the signal transduction underlying the conditioning phenomena, including their physical and chemical triggers, intracellular signal transduction, and effector mechanisms, notably in the mitochondria. Cardioprotective signal transduction appears as a highly concerted spatiotemporal program. Although the translation of ischemic postconditioning and remote ischemic conditioning protocols to patients with acute myocardial infarction has been fairly successful, the pharmacological recruitment of cardioprotective signaling has been largely disappointing to date.
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Affiliation(s)
- Gerd Heusch
- From the Institute for Pathophysiology, West German Heart and Vascular Centre, University of Essen Medical School, Essen, Germany.
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25
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Headrick JP, See Hoe LE, Du Toit EF, Peart JN. Opioid receptors and cardioprotection - 'opioidergic conditioning' of the heart. Br J Pharmacol 2015; 172:2026-50. [PMID: 25521834 PMCID: PMC4386979 DOI: 10.1111/bph.13042] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 11/18/2014] [Accepted: 12/09/2014] [Indexed: 12/21/2022] Open
Abstract
Ischaemic heart disease (IHD) remains a major cause of morbidity/mortality globally, firmly established in Westernized or 'developed' countries and rising in prevalence in developing nations. Thus, cardioprotective therapies to limit myocardial damage with associated ischaemia-reperfusion (I-R), during infarction or surgical ischaemia, is a very important, although still elusive, clinical goal. The opioid receptor system, encompassing the δ (vas deferens), κ (ketocyclazocine) and μ (morphine) opioid receptors and their endogenous opioid ligands (endorphins, dynorphins, enkephalins), appears as a logical candidate for such exploitation. This regulatory system may orchestrate organism and organ responses to stress, induces mammalian hibernation and associated metabolic protection, triggers powerful adaptive stress resistance in response to ischaemia/hypoxia (preconditioning), and mediates cardiac benefit stemming from physical activity. In addition to direct myocardial actions, central opioid receptor signalling may also enhance the ability of the heart to withstand I-R injury. The δ- and κ-opioid receptors are strongly implicated in cardioprotection across models and species (including anti-infarct and anti-arrhythmic actions), with mixed evidence for μ opioid receptor-dependent protection in animal and human tissues. A small number of clinical trials have provided evidence of cardiac benefit from morphine or remifentanil in cardiopulmonary bypass or coronary angioplasty patients, although further trials of subtype-specific opioid receptor agonists are needed. The precise roles and utility of this GPCR family in healthy and diseased human myocardium, and in mediating central and peripheral survival responses, warrant further investigation, as do the putative negative influences of ageing, IHD co-morbidities, and relevant drugs on opioid receptor signalling and protective responses.
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Affiliation(s)
- John P Headrick
- Heart Foundation Research Centre, Griffith Health Institute Griffith UniversitySouthport, Qld., Australia
| | - Louise E See Hoe
- Heart Foundation Research Centre, Griffith Health Institute Griffith UniversitySouthport, Qld., Australia
| | - Eugene F Du Toit
- Heart Foundation Research Centre, Griffith Health Institute Griffith UniversitySouthport, Qld., Australia
| | - Jason N Peart
- Heart Foundation Research Centre, Griffith Health Institute Griffith UniversitySouthport, Qld., Australia
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26
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Heusch G, Bøtker HE, Przyklenk K, Redington A, Yellon D. Remote ischemic conditioning. J Am Coll Cardiol 2015; 65:177-95. [PMID: 25593060 PMCID: PMC4297315 DOI: 10.1016/j.jacc.2014.10.031] [Citation(s) in RCA: 470] [Impact Index Per Article: 52.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 10/16/2014] [Accepted: 10/22/2014] [Indexed: 12/12/2022]
Abstract
In remote ischemic conditioning (RIC), brief, reversible episodes of ischemia with reperfusion in one vascular bed, tissue, or organ confer a global protective phenotype and render remote tissues and organs resistant to ischemia/reperfusion injury. The peripheral stimulus can be chemical, mechanical, or electrical and involves activation of peripheral sensory nerves. The signal transfer to the heart or other organs is through neuronal and humoral communications. Protection can be transferred, even across species, with plasma-derived dialysate and involves nitric oxide, stromal derived factor-1α, microribonucleic acid-144, but also other, not yet identified factors. Intracardiac signal transduction involves: adenosine, bradykinin, cytokines, and chemokines, which activate specific receptors; intracellular kinases; and mitochondrial function. RIC by repeated brief inflation/deflation of a blood pressure cuff protects against endothelial dysfunction and myocardial injury in percutaneous coronary interventions, coronary artery bypass grafting, and reperfused acute myocardial infarction. RIC is safe and effective, noninvasive, easily feasible, and inexpensive.
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Affiliation(s)
- Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Centre Essen, University of Essen Medical School, Essen, Germany.
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Karin Przyklenk
- Cardiovascular Research Institute, Wayne State University School of Medicine, Detroit, Michigan
| | - Andrew Redington
- Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Derek Yellon
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
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27
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Lu Y, Hu J, Zhang Y, Dong CS, Wong GTC. Remote intrathecal morphine preconditioning confers cardioprotection via spinal cord nitric oxide/cyclic guanosine monophosphate/protein kinase G pathway. J Surg Res 2014; 193:43-51. [PMID: 25214258 DOI: 10.1016/j.jss.2014.08.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 07/22/2014] [Accepted: 08/08/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND Remote intrathecal morphine preconditioning (RMPC) induces cardioprotection, but the underlying mechanisms of this effect is unknown. The aim of this study was to investigate the role of spinal cord nitric oxide/cyclic guanosine monophosphate/protein kinase G (NO/cGMP/PKG) signal pathway in the cardioprotection of RMPC in rats. MATERIALS AND METHODS Anesthetized, open chest, male Sprague-Dawley rats were assigned to one of eight treatment groups 3 d after intrathecal catheter placement. Before ischemia and reperfusion, RMPC received intrathecal morphine (3 μg/kg) by three cycles of 5-min infusions interspersed with 5-min infusion free periods. Intrathecally administrated a nonspecific nitric oxide synthase (NOS) inhibitor Nω-Nitro-L-arginine methyl ester (30 nmol), a specific guanylate cyclase inhibitor oxadiazolo [4,3-a] quinoxalin-1-one (11 nmol) and PKG inhibitor KT-5823 (20 pmol) 10 min before RMPC was used to evaluate the role of NO/cGMP/PKG of spinal cord. Ischemia and reperfusion injury were then induced by 30 min of left coronary artery occlusion, followed by 120 min of reperfusion. Infarct size, as a percentage of the area at risk, was determined by 2,3,5-triphenyltetrazolium staining. The content of cyclic guanosine monophosphate in the thoracic spinal cord was determined by radioimmunity protocol; the contents of nitric oxide and activity of NOS in the thoracic spinal cord were determined by nitrate reductase reduction and colorimetric methods; the expression of neuronal NOS (nNOS) and PKG in the thoracic spinal cord were determined by immunohistochemical and Western blotting method; the expression of nNOS messenger RNA was determined by reverse transcription-polymerase chain reaction method. RESULTS RMPC group markedly reduced the infarct size compared with the control group. However, the cardioprotection of RMPC could be abolished by pretreatment with Nω-Nitro-L-arginine methyl ester, Oxadiazolo [4,3-a] quinoxalin-1-one, and KT-5823. RMPC enhanced nitric oxide , NOS, and cyclic guanosine monophosphate levels in the spinal cord. Meanwhile, RMPC increased PKG and nNOS protein or messenger RNA expression in the spinal cord. CONCLUSIONS Spinal cord NO/cGMP/PKG signaling pathway mediates RMPC-induced cardioprotective effect.
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Affiliation(s)
- Yao Lu
- Department of Anesthesiology, Second Affiliated Hospital of Anhui Medical University, Hefei, China; Department of Anesthesiology, Third Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jun Hu
- Department of Anesthesiology, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ye Zhang
- Department of Anesthesiology, Second Affiliated Hospital of Anhui Medical University, Hefei, China.
| | - Chun Shan Dong
- Department of Anesthesiology, Third Affiliated Hospital of Anhui Medical University, Hefei, China
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See Hoe LE, Schilling JM, Tarbit E, Kiessling CJ, Busija AR, Niesman IR, Du Toit E, Ashton KJ, Roth DM, Headrick JP, Patel HH, Peart JN. Sarcolemmal cholesterol and caveolin-3 dependence of cardiac function, ischemic tolerance, and opioidergic cardioprotection. Am J Physiol Heart Circ Physiol 2014; 307:H895-903. [PMID: 25063791 DOI: 10.1152/ajpheart.00081.2014] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cholesterol-rich caveolar microdomains and associated caveolins influence sarcolemmal ion channel and receptor function and protective stress signaling. However, the importance of membrane cholesterol content to cardiovascular function and myocardial responses to ischemia-reperfusion (I/R) and cardioprotective stimuli are unclear. We assessed the effects of graded cholesterol depletion with methyl-β-cyclodextrin (MβCD) and lifelong knockout (KO) or overexpression (OE) of caveolin-3 (Cav-3) on cardiac function, I/R tolerance, and opioid receptor (OR)-mediated protection. Langendorff-perfused hearts from young male C57Bl/6 mice were untreated or treated with 0.02-1.0 mM MβCD for 25 min to deplete membrane cholesterol and disrupt caveolae. Hearts were subjected to 25-min ischemia/45-min reperfusion, and the cardioprotective effects of morphine applied either acutely or chronically [sustained ligand-activated preconditioning (SLP)] were assessed. MβCD concentration dependently reduced normoxic contractile function and postischemic outcomes in association with graded (10-30%) reductions in sarcolemmal cholesterol. Cardioprotection with acute morphine was abolished with ≥20 μM MβCD, whereas SLP was more robust and only inhibited with ≥200 μM MβCD. Deletion of Cav-3 also reduced, whereas Cav-3 OE improved, myocardial I/R tolerance. Protection via SLP remained equally effective in Cav-3 KO mice and was additive with innate protection arising with Cav-3 OE. These data reveal the membrane cholesterol dependence of normoxic myocardial and coronary function, I/R tolerance, and OR-mediated cardioprotection in murine hearts (all declining with cholesterol depletion). In contrast, baseline function appears insensitive to Cav-3, whereas cardiac I/R tolerance parallels Cav-3 expression. Novel SLP appears unique, being less sensitive to cholesterol depletion than acute OR protection and arising independently of Cav-3 expression.
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Affiliation(s)
- Louise E See Hoe
- Heart Foundation Research Centre, Griffith Health Institute, Griffith University, Southport, Queensland, Australia
| | - Jan M Schilling
- Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Emiri Tarbit
- Heart Foundation Research Centre, Griffith Health Institute, Griffith University, Southport, Queensland, Australia
| | - Can J Kiessling
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia; and
| | - Anna R Busija
- Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Ingrid R Niesman
- Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Eugene Du Toit
- Heart Foundation Research Centre, Griffith Health Institute, Griffith University, Southport, Queensland, Australia
| | - Kevin J Ashton
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia; and
| | - David M Roth
- Veterans Affairs San Diego Healthcare System, San Diego, California; Department of Anesthesiology, University of California, San Diego, California
| | - John P Headrick
- Heart Foundation Research Centre, Griffith Health Institute, Griffith University, Southport, Queensland, Australia
| | - Hemal H Patel
- Veterans Affairs San Diego Healthcare System, San Diego, California; Department of Anesthesiology, University of California, San Diego, California
| | - Jason N Peart
- Heart Foundation Research Centre, Griffith Health Institute, Griffith University, Southport, Queensland, Australia;
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Abstract
This paper is the thirty-fifth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2012 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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30
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Costa JF, Fontes-Carvalho R, Leite-Moreira AF. Myocardial remote ischemic preconditioning: From pathophysiology to clinical application. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.repce.2013.10.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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31
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Kang SW, Kim OK, Seo B, Lee SH, Quan FS, Shin JH, Lee GJ, Park HK. Simultaneous, real-time measurement of nitric oxide and oxygen dynamics during cardiac ischemia–reperfusion of the rat utilizing sol–gel-derived electrochemical microsensors. Anal Chim Acta 2013; 802:74-81. [DOI: 10.1016/j.aca.2013.09.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 08/21/2013] [Accepted: 09/16/2013] [Indexed: 12/29/2022]
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32
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Costa JF, Fontes-Carvalho R, Leite-Moreira AF. Pré-condicionamento isquémico remoto do miocárdio: dos mecanismos fisiopatológicos à aplicação na prática clínica. Rev Port Cardiol 2013; 32:893-904. [DOI: 10.1016/j.repc.2013.02.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 02/21/2013] [Indexed: 12/14/2022] Open
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Maslov LN, Naryzhnaia NV, Tsibulnikov SY, Kolar F, Zhang Y, Wang H, Gusakova AM, Lishmanov YB. Role of endogenous opioid peptides in the infarct size-limiting effect of adaptation to chronic continuous hypoxia. Life Sci 2013; 93:373-9. [PMID: 23891777 DOI: 10.1016/j.lfs.2013.07.018] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 06/27/2013] [Accepted: 07/15/2013] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Leonid N Maslov
- Laboratory Experimental Cardiology, Research Institute for Cardiology, Siberian Branch of the Russian Academy of Medical Sciences, Tomsk 634012, Russia.
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Wever KE, Masereeuw R, Wagener FA, Verweij VG, Peters JG, Pertijs JC, Van der Vliet JA, Warlé MC, Rongen GA. Humoral signalling compounds in remote ischaemic preconditioning of the kidney, a role for the opioid receptor. Nephrol Dial Transplant 2013; 28:1721-32. [DOI: 10.1093/ndt/gfs601] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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