Eplerenone inhibits the intracrine and extracellular actions of angiotensin II on the inward calcium current in the failing heart. On the presence of an intracrine renin angiotensin aldosterone system

Intracellular angiotensin II disrupts chemical communication and impairs metabolic cooperation between cardiac myocytes

The influence of intracellular angiotensin II (Ang II) on the process of chemical communication and metabolic cooperation between cardiac cells is discussed. Emphasis is given to the influence of pathological conditions like heart failure, myocardial ischemia or hyperglycemia on the activation of the intracrine renin angiotensin aldosterone system (RAAS) and its consequence for the metabolic cooperation between heart cells. Furthermore, the influence of high glucose on the process of chemical communication was described as well as its implication for the failing and diabetic heart. The major conclusion is that the activation of the intracrine renin angiotensin induced by heart failure, hyperglycemia, aldosterone or myocardial ischemia generates metabolic imbalance in the heart with serious consequences for the cardiac function.

Aldosterone Disrupts the Intercellular Flow of Glucose in Cardiac Muscle

The activation of the renin-angiotensin system is known to impair intercellular communication in the heart, but the role of aldosterone on the process of chemical communication and particularly the intercellular diffusion of glucose between cardiomyocytes is not known. This problem was investigated in cell pairs isolated from the left ventricle of adult Wistar Kyoto rats. For this, fluorescent glucose was dialyzed into one cell of the pair using the whole cell clamp technique, and its diffusion from cell-to-cell through gap junctions was followed by measuring the fluorescence intensity in the dialyzed as well as in non-dialyzed cell as a function of time. The results indicated that (1) in cell pairs exposed to aldosterone (100 nM) for 24 h, the intercellular flow of glucose through gap junctions was disrupted; (2) although the mechanism by which aldosterone disrupts the cell-to-cell flow of glucose is multifactorial, two major factors are involved: oxidative stress and PKC activation; (3) the effect of aldosterone was significantly reduced by spironolactone (100 nM); and (4) calculation of gap junction permeability (Pj) indicated an average values of 0.3 ± 0.001 × 10(-4) cm/s (n = 31) (four animals) for controls and 24 ± 0.03 × 10(-6) cm/s (n = 34) (four animals) (P < 0.05) for cell pairs exposed to aldosterone (100 nM) for 24 h. Bis-1 (10(-9)M), which is a selective PKC inhibitor, added to the aldosterone solution, improved the value of Pj to 0.21 ± 0.001 × 10(-4) cm/s (n = 24) (P < 0.05), whereas spironolactone (100 nM) added to aldosterone solution, reduced significantly the effect of the hormone on junctional permeability to glucose.

The impact of age-related dysregulation of the angiotensin system on mitochondrial redox balance

Aging is associated with the accumulation of various deleterious changes in cells. According to the free radical and mitochondrial theory of aging, mitochondria initiate most of the deleterious changes in aging and govern life span. The failure of mitochondrial reduction-oxidation (redox) homeostasis and the formation of excessive free radicals are tightly linked to dysregulation in the Renin Angiotensin System (RAS). A main rate-controlling step in RAS is renin, an enzyme that hydrolyzes angiotensinogen to generate angiotensin I. Angiotensin I is further converted to Angiotensin II (Ang II) by angiotensin-converting enzyme (ACE). Ang II binds with equal affinity to two main angiotensin receptors—type 1 (AT₁R) and type 2 (AT₂R). The binding of Ang II to AT₁R activates NADPH oxidase, which leads to increased generation of cytoplasmic reactive oxygen species (ROS). This Ang II-AT₁R–NADPH-ROS signal triggers the opening of mitochondrial K_ATP channels and mitochondrial ROS production in a positive feedback loop. Furthermore, RAS has been implicated in the decrease of many of ROS scavenging enzymes, thereby leading to detrimental levels of free radicals in the cell. AT₂R is less understood, but evidence supports an anti-oxidative and mitochondria-protective function for AT₂R. The overlap between age related changes in RAS and mitochondria, and the consequences of this overlap on age-related diseases are quite complex. RAS dysregulation has been implicated in many pathological conditions due to its contribution to mitochondrial dysfunction. Decreased age-related, renal and cardiac mitochondrial dysfunction was seen in patients treated with angiotensin receptor blockers. The aim of this review is to: (a) report the most recent information elucidating the role of RAS in mitochondrial redox hemostasis and (b) discuss the effect of age-related activation of RAS on generation of free radicals.

Eplerenone: a review of its use in patients with chronic systolic heart failure and mild symptoms

Eplerenone (Inspra®) is a selective mineralocorticoid receptor antagonist (MRA). In the EU, it is approved for use (in addition to standard optimal therapy) to reduce the risk of cardiovascular (CV) mortality and morbidity in adult patients with chronic systolic heart failure (HF) and mild symptoms. This article reviews the efficacy and tolerability of eplerenone in this indication and briefly summarizes its pharmacology. In the EMPHASIS-HF study, relative to placebo, the addition of eplerenone to optimal background therapy significantly reduced the risk of death from CV causes or hospitalization for HF in patients with chronic systolic HF and mild symptoms. Benefits of eplerenone therapy over placebo were also observed in several secondary outcomes, including: death from any cause or hospitalization for HF; death from any cause; hospitalization for any reason; or hospitalization for HF. Eplerenone was generally well tolerated in this study, with the most frequent adverse event being hyperkalaemia, which is a known adverse event of the drug class. Sexual adverse events (e.g. gynecomastia) occurred in <1 % of eplerenone recipients, reflecting the selectivity of eplerenone for mineralocorticoid receptors. Based on these results, European guidelines have been updated and recommend the use of an MRA to reduce the risk of HF hospitalization and premature death in all patients with persisting symptoms (New York Heart Association class II-IV) and a left-ventricular ejection fraction of ≤35 %, despite treatment with ACE inhibitor (or an angiotensin receptor blocker if an ACE inhibitor is not tolerated) and a β-blocker.

Intracellular Renin Disrupts Chemical Communication between Heart Cells. Pathophysiological Implications

HighlightsIntracellular renin disrupts chemical communication in the heartAngiotensinogen enhances the effect of reninIntracellular enalaprilat reduces significantly the effect of reninIntracellular renin increases the inward calcium currentHarmful versus beneficial effect during myocardial infarction The influence of intracellular renin on the process of chemical communication between cardiac cells was investigated in cell pairs isolated from the left ventricle of adult Wistar Kyoto rats. The enzyme together with Lucifer yellow CH was dialyzed into one cell of the pair using the whole cell clamp technique. The diffusion of the dye in the dialyzed and in non-dialyzed cell was followed by measuring the intensity of fluorescence in both cells as a function of time. The results indicated that; (1) under normal conditions, Lucifer Yellow flows from cell to cell through gap junctions; (2) the intracellular dialysis of renin (100 nM) disrupts chemical communication - an effect enhanced by simultaneous administration of angiotensinogen (100 nM); (3) enalaprilat (10(-9) M) administered to the cytosol together with renin reduced drastically the uncoupling action of the enzyme; (4) aliskiren (10(-8) M) inhibited the effect of renin on chemical communication; (5) the possible role of intracellular renin independently of angiotensin II (Ang II) was evaluated including the increase of the inward calcium current elicited by the enzyme and the possible role of oxidative stress on the disruption of cell communication; (6) the possible harmful versus the beneficial effect of intracellular renin during myocardial infarction was discussed; (7) the present results indicate that intracellular renin due to internalization or in situ synthesis causes a severe impairment of chemical communication in the heart resulting in derangement of metabolic cooperation with serious consequences for heart function.

Clinical perspectives and fundamental aspects of local cardiovascular and renal Renin-Angiotensin systems

Evidence for the potential role of organ specific cardiovascular renin-angiotensin systems (RAS) has been demonstrated experimentally and clinically with respect to certain cardiovascular and renal diseases. These findings have been supported by studies involving pharmacological inhibition during ischemic heart disease, myocardial infarction, cardiac failure; hypertension associated with left ventricular ischemia, myocardial fibrosis and left ventricular hypertrophy; structural and functional changes of the target organs associated with prolonged dietary salt excess; and intrarenal vascular disease associated with end-stage renal disease. Moreover, the severe structural and functional changes induced by these pathological conditions can be prevented and reversed by agents producing RAS inhibition (even when not necessarily coincident with alterations in arterial pressure). In this review, we discuss specific fundamental and clinical aspects and mechanisms related to the activation or inhibition of local RAS and their implications for cardiovascular and renal diseases. Fundamental aspects involving the role of angiotensins on cardiac and renal functions including the expression of RAS components in the heart and kidney and the controversial role of angiotensin-converting enzyme 2 on angiotensin peptide metabolism in humans, were discussed.

Mineralocorticoid receptors and the heart, multiple cell types and multiple mechanisms: a focus on the cardiomyocyte

MR (mineralocorticoid receptor) activation in the heart plays a central role in the development of cardiovascular disease, including heart failure. The MR is present in many cell types within the myocardium, including cardiomyocytes, macrophages and the coronary vasculature. The specific role of the MR in each of these cell types in the initiation and progression of cardiac pathophysiology is not fully understood. Cardiomyocyte MRs are increasingly recognized to play a role in regulating cardiac function, electrical conduction and fibrosis, through direct signal mediation and through paracrine MR-dependent activity. Although MR blockade in the heart is an attractive therapeutic option for the treatment of heart failure and other forms of heart disease, current antagonists are limited by side effects owing to MR inactivation in other tissues (including renal targets). This has led to increased efforts to develop therapeutics that are more selective for cardiac MRs and which may have reduced the occurrence of side effects in non-cardiac tissues. A major clinical consideration in the treatment of cardiovascular disease is of the differences between males and females in the incidence and outcomes of cardiac events. There is clinical evidence that female sensitivity to endogenous MRs is more pronounced, and experimentally that MR-targeted interventions may be more efficacious in females. Given that sex differences have been described in MR signalling in a range of experimental settings and that the MR and oestrogen receptor pathways share some common signalling intermediates, it is becoming increasingly apparent that the mechanisms of MRs need to be evaluated in a sex-selective manner. Further research targeted to identify sex differences in cardiomyocyte MR activation and signalling processes has the potential to provide the basis for the development of cardiac-specific MR therapies that may also be sex-specific.

Spironolactone enhances the beneficial effect of aliskiren on cardiac structural and electrical remodeling in TGR(mRen2)27 rats

OBJECTIVE

To investigate the influence of simultaneous administration of spironolactone (20 mg/kg per day, intraperitoneal (i.p.)) and aliskiren (50 mg/kg per day, i.p.) for a period of eight weeks on cardiac remodeling in TGR(mRen2)27 rats.

METHODS

Echocardiographic and electrophysiological and histological methods were used to determine the influence of spironolactone and aliskiren on cardiac remodeling.

RESULTS

1) the beneficial effect of aliskiren on SBP was enhanced by simultaneous administration of spironolactone; 2) echocardiographic studies showed that the left ventricle diameter (LVD), the left ventricle end diastolic volume (LVEDV) and the left ventricle posterior wall thickness (LVPW) were significantly reduced by the combination of both drugs when compared with aliskiren alone; 3) the ejection fraction was also increased; 4) histological studies indicated a greater decline in perivascular and interstitial fibrosis when both drugs were used; 5) the decrease of electrical remodeling of the left ventricle caused by aliskiren was further reduced by simultaneous administration of spironolactone; 6) the cardiac refractoriness increased by aliskiren was further incremented by spironolactone. Spironolactone (20 mg/kg per day) alone increased the ejection fraction and reduced LVD, LVEDV and LVPW but its effect was smaller than that achieved with the combination spironolactone plus aliskiren.

CONCLUSION

The combination of an aldosterone inhibitor with a direct renin inhibitor proved to be of greater benefit for cardiac structural and electrical remodeling in this experimental model of hypertension than aliskiren alone.

Intracellular renin alters the electrical properties of the intact heart ventricle of adult Sprague Dawley rats

The influence of intracellular renin injection on the electrical properties of the intact left ventricle from adult Sprague Dawley rat heart was investigated. Intracellular renin injection was performed using intracellular microelectrodes filled with solution containing renin (120pM). Pressure pulses (40-70psi) for short periods of time (20ms), were applied to the micropipette while recording the action potential simultaneously from the same fiber. The results indicated that intracellular renin caused a depolarization of ventricular fibers of 7.3±2±mV (n=38) (4 animals) (P<0.05) and a decrease of the action potential duration at 50% and at 90% repolarization, respectively. Moreover, the refractoriness was significantly decreased with consequent generation of triggered activity. The effect of intracellular renin was seen within 3min of enzyme injection. The shortening of the action potential was related to an increase of potassium current which was measured in isolated ventricular myocytes before and after intracellular dialysis of renin (10(-9)M) using a voltage whole cell clamp configuration. Valsartan (10(-8)M) dialyzed together with renin (120pM) into the cell decreased drastically the effect of renin on potassium current. An increment of potassium current was also found when intracellular renin was dialyzed into cardiomyocytes exposed to Krebs solution containing valsartan (10(-8)M) for 10min prior to renin administration. Bis-1 which is a specific inhibitor of PKC, abolished the effect of intracellular renin on potassium current.

IN CONCLUSION

intracellular renin decreases the action potential duration and cardiac refractoriness in the intact left ventricle of adult Sprague Dawley rats. The shortening of the action potential was related to an increase in total potassium current. The effect of renin on total potassium currents was inhibited by valsartan and by Bis-1. Implication for cardiac arrhythmias was discussed.

The intracrine renin-angiotensin system

The RAS (renin-angiotensin system) is one of the earliest and most extensively studied hormonal systems. The RAS is an atypical hormonal system in several ways. The major bioactive peptide of the system, AngII (angiotensin II), is neither synthesized in nor targets one specific organ. New research has identified additional peptides with important physiological and pathological roles. More peptides also mean newer enzymatic cascades that generate these peptides and more receptors that mediate their function. In addition, completely different roles of components that constitute the RAS have been uncovered, such as that for prorenin via the prorenin receptor. Complexity of the RAS is enhanced further by the presence of sub-systems in tissues, which act in an autocrine/paracrine manner independent of the endocrine system. The RAS seems relevant at the cellular level, wherein individual cells have a complete system, termed the intracellular RAS. Thus, from cells to tissues to the entire organism, the RAS exhibits continuity while maintaining independent control at different levels. The intracellular RAS is a relatively new concept for the RAS. The present review provides a synopsis of the literature on this system in different tissues.

Intracardiac intracellular angiotensin system in diabetes

The renin-angiotensin system (RAS) has mainly been categorized as a circulating and a local tissue RAS. A new component of the local system, known as the intracellular RAS, has recently been described. The intracellular RAS is defined as synthesis and action of ANG II intracellularly. This RAS appears to differ from the circulating and the local RAS, in terms of components and the mechanism of action. These differences may alter treatment strategies that target the RAS in several pathological conditions. Recent work from our laboratory has demonstrated significant upregulation of the cardiac, intracellular RAS in diabetes, which is associated with cardiac dysfunction. Here, we have reviewed evidence supporting an intracellular RAS in different cell types, ANG II's actions in cardiac cells, and its mechanism of action, focusing on the intracellular cardiac RAS in diabetes. We have discussed the significance of an intracellular RAS in cardiac pathophysiology and implications for potential therapies.

Lessons from in vitro studies and a related intracellular angiotensin II transgenic mouse model

In the classical renin-angiotensin system, circulating ANG II mediates growth stimulatory and hemodynamic effects through the plasma membrane ANG II type I receptor, AT1. ANG II also exists in the intracellular space in some native cells, and tissues and can be upregulated in diseases, including hypertension and diabetes. Moreover, intracellular AT1 receptors can be found associated with endosomes, nuclei, and mitochondria. Intracellular ANG II can function in a canonical fashion through the native receptor and also in a noncanonical fashion through interaction with alternative proteins. Likewise, the receptor and proteolytic fragments of the receptor can function independently of ANG II. Participation of the receptor and ligand in alternative intracellular pathways may serve to amplify events that are initiated at the plasma membrane. We review historical and current literature relevant to ANG II, compared with other intracrines, in tissue culture and transgenic models. In particular, we describe a new transgenic mouse model, which demonstrates that intracellular ANG II is linked to high blood pressure. Appreciation of the diverse, pleiotropic intracellular effects of components of the renin-angiotensin system should lead to alternative disease treatment targets and new therapies.

On the local cardiac renin angiotensin system. Basic and clinical implications

In the present review we reevaluated the experimental and clinical evidence that there is a local renin angiotensin system in the heart as well as the presence of a functional intracrine component which is activated during pathological conditions like heart failure and hypertension. The implications of these findings for cardiology were discussed. The novel finding that cell swelling impairs cell coupling and impulse propagation through activation of ionic channels with consequent generation of cardiac arrhythmias and the evidence that AT1 receptors are mechanosensors able to alter the heart function independently of Ang II were discussed. Particular attention was given to the role of salt loading on the activation of a local cardiac renin angiotensin and its consequences.

Intracrine action of angiotensin II in the intact ventricle of the failing heart: angiotensin II changes cardiac excitability from within

The influence of intracellular injection of angiotensin II (Ang II) on electrical properties of single right ventricular fibers from the failing heart of cardiomyopathic hamsters (TO2) was investigated in the intact ventricle of 8-month-old animals. Intracellular injection was performed using pressure pulses (40-70 psi) for short periods of time (20 ms) while recoding the action potential simultaneously from the same fiber. The results indicated that intracellular Ang II caused a hyperpolarization of 7.7 mV ± 4.3 mV (n = 39) (4 animals) (P < 0.05) followed by a small fall in membrane potential. The action potential duration was significantly increased at 50% and at 90% repolarization, and the refractoriness was significantly enhanced. The effect of intracellular Ang II on action potential duration was related to the inhibition of potassium conductance through PKC activation because Bis-1 (360 nM), a selective PKC inhibitor, abolished the effect of the peptide. Injections performed in different fibers of the same ventricle showed a variable effect of Ang II on action potential duration and generated spontaneous rhythmicity. The effect of intracellular Ang II on action potential duration and cardiac refractoriness remains for more than 1 h after interruption of the intracellular injection of the peptide.

Further studies on the effects of intracrine and extracellular angiotensin II on the regulation of heart cell volume. On the influence of aldosterone and spironolactone

The influence of extracellular and intracellular angiotensin II (Ang II) on the cell volume in the failing heart of cardiomyopathic hamsters (TO2) was further investigated as well as the influence of aldosterone and spironolactone on the Ang II action on cell volume. Measurements of cell width and area of quiescent ventricular cardiomyocytes were performed using a video camera and computer analysis and the relative cell volume was calculated. All measurements of cell volume were performed in the same cell before and after the administration of Ang II (10⁻⁸M). The results indicated that: a) the increase in cell volume caused by extracellular Ang II(10⁻⁸ M) was enhanced in cells incubated with aldosterone (100 nM) for 48 h; b) the effect of aldosterone was abolished by spironolactone (10⁻⁸ M); c) the decline in cell volume elicited by intracellular administration of Ang II (10⁻⁸ M) was increased by aldosterone and inhibited by spironolactone; d) the effects of aldosterone and spironolactone were related, in part, to a change in expression of AT1 receptors; and e) the intracellular administration of Ang II reduced the swelling-dependent chloride current (I(Clswell)). The implications of these findings to the failing heart and myocardial ischemia are discussed.

Effects of aldosterone on coronary function

Our understanding of the effects of aldosterone and its mechanisms has increased substantially in recent years, probably because of the importance of the mineralocorticoid receptor (MR) antagonists in several major cardiovascular diseases. Recent clinical studies have confirmed the benefits of MR antagonists in patients with heart failure, left ventricular dysfunction after myocardial infarction, hypertension or diabetic nephropathy. However, it would be a gross oversimplification to conclude that the role of aldosterone is unequivocally negative. Aldosterone is synthesized in the adrenal glands and binds to specific MRs in target epithelial cells. The steroid-receptor complex penetrates the cell nucleus where it modulates gene expression and activates specific aldosterone-induced proteins that control sodium reabsorption. Recent studies have shown that aldosterone also impacts a wide range of non-epithelial tissues such as the heart and blood vessels. Remarkably, aldosterone can also be synthesized in extra-adrenal tissues and it may act in a rapid non-genomic manner.We note the existence of glucocorticoids that exhibit plasma concentrations much higher than those of aldosterone and that are structurally very similar to aldosterone. It is thus possible that glucocorticoids may bind to the aldosterone receptor in some cell types. Diverse experimental models and several strains of transgenic mice have allowed us to better understand the effects of aldosterone on the heart. Specifically, it seems that a slight increase in cardiac aldosterone concentrations induces a decreased coronary reserve in mice by decreasing the BKCa potassium channels associated with coronary smooth muscle cells. Taken together, these experiments indicate that vascular cells are the primary targets of aldosterone in the cardiovascular system. The hormone directly affects NO and EDHF-mediated coronary relaxation. Both mechanisms may contribute to the deleterious cardiovascular effects of MR stimulation.

New insights into target organ involvement in hypertension

Hypertension and its sequelae are complex processes. Optimization of the care of the hypertensive patient requires not only attention to the regulation of arterial pressure but also attention to blunting the hypertension-related processes that lead to vascular disease. It is clear that the regulation of these processes is much more complex than previously understood. Here several new insights into the pathogenesis of hypertension-related vascular disease have been explored. While this review is not exhaustive, it does serve to point out the varied nature of the biologic processes that must be taken into account and it points to new avenues for the development of therapeutic agents.