Attenuation of epinephrine-induced dysrhythmias by bradykinin: role of nitric oxide and prostaglandins

Cardioprotection by methylene Blue Against Epinephrine-Induced Cardiac Arrhythmias and Myocardial Injury

Methylene blue is used in the treatment of vasoplegic syndrome after cardiac surgery, anaphylaxis, and septic shock refractory to epinephrine and fluid resuscitation. In this study, we investigated the potential protective effect of methylene blue on the development of cardiac arrhythmias after injection of epinephrine in rats. Methylene blue was given intraperitoneally at doses of 50 or 100 mg/kg. Cardiac arrhythmia was then induced with 10 μg/kg of epinephrine intravenously. In untreated, control rats, epinephrine caused bradycardia (96.48 ± 1.06 vs. 365.03 ± 0.68 beats/min), increased PR interval (0.54 ± 0.04 vs. 0.039 ± 0.004), RR interval (0.64 ± 0.003 vs. 0.16 ± 0.004 sec), shortened QTc interval (0.067 ± 0.05 vs. 0.1 ± 0.004 sec), increased QRS duration (0.048 ± 0.005 vs. 0.028 ± 0.002 sec), decreased R wave amplitude (0.3 ± 0.03 vs. 0.49 ± 0.04 mv), decreased the height of the ST segment (-0.0696 ± 0.004 vs. -0.0054 ± 0.003 mv), and caused ventricular extrasystoles (7.92 ± 0.56 vs. 0.5 ± 0.5). Methylene blue given at 50 or 100 mg/kg increased the heart rate, decreased RR interval, QRS duration and the drop in the ST height, increased duration of QTc interval and R wave amplitude and decreased the number of extrasystoles. The histological study showed that methylene blue protected against myocardial structural disorganization, cellular damage, necrosis, and haemorrhage between muscle fibres induced by epinephrine injection. We conclude that methylene blue dose-dependently prevented epinephrine-induced arrhythmias and cardiac muscle injury.

Perioperative Inotrope Therapy and Atrial Fibrillation Following Coronary Artery Bypass Graft Surgery: Evidence of a Racial Disparity

BACKGROUND AND OBJECTIVE

Following coronary artery bypass graft (CABG) surgery, mortality rates are significantly higher among black patients who experience postoperative atrial fibrillation (POAF). Perioperative inotropic therapy (PINOT) was associated with POAF in previous reports, but the extent to which race influences this association is unknown. In the present study, the relationship between PINOT, race, and POAF was examined in patients undergoing CABG surgery.

METHODS AND SETTING

Clinical records were examined from a prospectively maintained cohort of 11,855 patients (median age 64 yrs; 70% male; 16% black) undergoing primary isolated CABG at a large cardiovascular institute in the southeastern region of the United States. Relative risk (RR) and 95% confidence intervals (CIs) were computed using log-binomial regression.

MAIN RESULTS

The association between PINOT and POAF was significantly increased among black patients (adjusted RR 1.7, CI 1.4-2.0) compared with white patients (adjusted RR 1.3, CI 1.2-1.4) (p_interaction  = 0.013).

CONCLUSIONS

These findings suggest that PINOT may be disproportionately associated with POAF among black patients undergoing CABG surgery. Additional studies are needed to examine further the potential underlying mechanisms of this association.

Extracellular and intracellular proteases in cardiac dysfunction due to ischemia-reperfusion injury

Various procedures such as angioplasty, thrombolytic therapy, coronary bypass surgery, and cardiac transplantation are invariably associated with ischemia-reperfusion (I/R) injury. Impaired recovery of cardiac function due to I/R injury is considered to be a consequence of the occurrence of both oxidative stress and intracellular Ca(2+)-overload in the myocardium. These changes in the ischemic myocardium appear to activate both extracellular and intracellular proteases which are responsible for the cleavage of extracellular matrix and subcellular structures involved in the maintenance of cardiac function. It is thus intended to discuss the actions of I/R injury on several proteases, with a focus on calpain, matrix metalloproteinases, and cathepsins as well as their role in inducing alterations both inside and outside the cardiomyocytes. In addition, modifications of subcellular organelles such as myofibrils, sarcoplasmic reticulum and sarcolemma as well as extracellular matrix, and the potential regulatory effects of endogenous inhibitors on protease activities are identified. Both extracellular and intracellular proteolytic activities appear to be imperative in determining the true extent of I/R injury and their inhibition seems to be of critical importance for improving the recovery of cardiac function. Thus, both extracellular and intracellular proteases may serve as potential targets for the development of cardioprotective interventions for reducing damage to the heart and retarding the development of contractile dysfunction caused by I/R injury.

Genetic variation in angiotensin-converting enzyme-related pathways associated with sudden cardiac arrest risk

BACKGROUND

Angiotensin-converting enzyme (ACE)-related pathways influence arrhythmias and sudden cardiac arrest (SCA) risk.

OBJECTIVE

The purpose of this study was to investigate whether genetic variations in ACE-related pathways are associated with SCA risk. Because these pathways are sex dependent and are influenced by estrogen, we examined these genotype-SCA associations in the full study population and tested for interaction with gender.

METHODS

In a population-based case-control study set in King County, Washington, 211 SCA cases (80% male; mean age 59 years,) and 730 age- and gender-matched controls of European descent were genotyped for 47 single nucleotide polymorphisms (SNPs) in eight genes (ACE, AGT, REN, AGTR1, AGTR2, ACE2, KNG1, BDKRB2). The association of SNPs and haplotypes with SCA risk was examined using logistic regression.

RESULTS

AGTR1 SNP rs1492099 (allele frequency 15%) was associated with decreased SCA risk (odds ratio [OR] 0.62, 95% confidence interval [CI] 0.4-0.9). Haplotype variation in AGTR2 was associated with SCA risk (global haplotype test P = .001), with haplotype 2 (allele frequency 27%) associated with increased risk (OR 1.26, 95% CI 1.1-1.5). There was interaction with gender on SCA risk for variation in KNG1 (interaction P value range 0.0004-0.017 for 6/8 SNPs). KNG1 SNP rs710448 (allele frequency 42%) was associated with decreased risk (OR 0.44, 95% CI 0.3-0.8) among women but not men. Other SNPs and haplotypes in the eight genes examined were not associated with SCA risk after multiple testing correction.

CONCLUSION

Variations in AGTR1 and AGTR2 are associated with SCA risk in a population-based case-control study. There was evidence of interaction with gender on SCA risk for variation in KNG1. These study findings, if replicated, suggest that variation in genes in ACE-related pathways influence SCA risk.

Reduced susceptibility to epinephrine-induced arrhythmias in cirrhotic rats: the roles of nitric oxide and endogenous opioid peptides

BACKGROUND/AIMS

The clinical relevance of QT prolongation, the most widely recognized cardiac electrophysiological abnormality of cirrhosis, is still undefined. The aim of this study is to examine the susceptibility of chronic (4-week) bile duct-ligated rats to epinephrine-induced arrhythmias. The roles of nitric oxide and endogenous opioids were also evaluated.

METHODS

Sham-operated and cirrhotic rats were treated with daily subcutaneous administrations of normal saline (1 ml/kg/day), L-NAME (a non-selective nitric oxide synthase inhibitor, 3mg/kg/day), and naltrexone (20mg/kg/day) during the fourth week after operation. In order to evaluate the effects of acute nitric oxide synthesis inhibition, additional groups of animals were treated by acute intraperitoneal L-NAME injections (3mg/kg). Arrhythmias were induced by intravenous injections of 10 microg/kg epinephrine.

RESULTS

Despite QT prolongation (P<0.001), epinephrine induced fewer arrhythmias in cirrhotic rats compared to sham-operated animals (P<0.05). Chronic, but not acute, L-NAME administration corrected the QT prolongation in cirrhotic rats (P<0.001), and restored the susceptibility of cirrhotic rats to arrhythmias (P<0.05). Naltrexone injection without a significant effect on epinephrine-induced arrhythmias corrected QT interval in cirrhotic rats (P<0.001).

CONCLUSIONS

This study shows that despite QT prolongation, cirrhotic animals are resistant against epinephrine-induced arrhythmias. This resistance is mediated by chronic nitric oxide overproduction.

Resistance of cholestatic rats against epinephrine-induced arrhythmia: the role of nitric oxide and endogenous opioids

Short-term ligation of bile duct has been used as a model to study acute cholestasis and is associated with various cardiovascular abnormalities. We examined the role of nitric oxide (NO) and endogenous opioids on epinephrine-induced arrhythmia in 7-day bile duct-ligated (BDL) rats. Six groups of rats, each of which was subdivided into two subgroups (sham-operated and BDL), were examined. First group of animals were chronically treated with normal saline. In the second and third groups, single intraperitoneal administration of N(omega)-nitro-L-arginine methyl ester (L-NAME, 10 mg/kg) or naltrexone (20 mg/kg) was performed 30 min before evaluation of epinephrine-induced arrhythmia. Two groups received chronic administration of low dose (3 mg/kg/day) or high dose (10 mg/kg/day) L-NAME; and the last group was treated chronically with naltrexone (20 mg/kg/day). Chronic drug administration was performed subcutaneously for 6 consecutive days following BDL or sham operation. After induction of arrhythmia by intravenous injection of 10 microg/kg epinephrine, mean arterial pressure and electrocardiogram were recorded for 1 min. Heart rate and mean arterial pressure were significantly lower in BDL rats (P<0.01). Chronic injection of naltrexone increased heart rate and mean arterial pressure in BDL (P<0.05). Chronic low dose L-NAME administration had no effect on baseline hemodynamic parameters. High dose L-NAME injection corrected hypotension in BDL rats, but not bradycardia (P<0.05). Epinephrine induced less arrhythmia in BDL rats (P<0.05). Acute and chronic injection of naltrexone had no effect on the resistance of BDL rats against epinephrine-induced arrhythmia. Although acute L-NAME administration enhanced arrhythmias in sham-operated rats (P<0.001), it had no effect on BDL animals. Chronic injection of low dose or high dose L-NAME, without having any effect on sham-operated animals, increased arrhythmias in BDL rats (P<0.01). This study showed that BDL animals are resistant against epinephrine-induced arrhythmia and this resistance depends on long-term NO overproduction.

Development of a Halothane-Adrenaline Arrhythmia Model Using In Vivo Guinea Pigs

In vivo antiarrhythmic effects of diltiazem hydrochloride and nifekalant hydrochloride, a pure class III antiarrhythmic drug (Vaughan Williams' classification), on adrenaline induced ventricular arrhythmias were examined in halothane anesthetized guinea pigs. Continuous adrenaline infusion (12.5 microg/kg per min) induced ventricular arrhythmias. Arrhythmogenicity was significantly increased with vagotomy and higher concentration of halothane. After injection of diltiazem at 0.5 mg/kg, the arrhythmic ratio (the number of ventricular ectopic beats divided by the total heart beats) was significantly reduced compared with the predrug control value (0.69 vs 0.04, P<0.05). No significant change of arrhythmic ratio was observed after injection of nifekalant (0.57 vs 0.61, ns). After administration of nifekalant, the mean minimum adrenaline infusion rate that induced ventricular arrhythmia decreased from 9.29 to 6.43 microg/kg per min. On the other hand, before administration of diltiazem, the mean arrhythmogenic rate of adrenaline was 8.50 microg/kg per min, but ventricular arrhythmias were no longer induced during continuous infusion of diltiazem at 0.5 mg/kg per min. These results were qualitatively consistent with previous experiments using the canine halothane-adrenaline model. In conclusion, the halothane-adrenaline arrhythmia model using the in vivo guinea pig is useful for screening drugs with potential anti- or pro-arrhythmic properties.

Effect of SIN-1 in rat ventricular myocytes: interference with beta-adrenergic stimulation

We have examined the effects of the nitric oxide (NO) donor, 3-morpholino-sydnonimine (SIN-1), on Ca(2+) transients, L-type Ca(2+) current (I(Ca,L)), and cGMP/cAMP content in electrically-stimulated rat ventricular myocytes in the absence and presence of the beta-adrenergic stimulation with isoproterenol. SIN-1 had no effect at low concentrations, but decreased the amplitude of electrically-induced Ca(2+) transients at higher concentrations. SIN-1 attenuated the increase in Ca(2+) transients induced by isoproterenol in a concentration-dependent manner. SIN-1 Also reduced the amplitude of caffeine-induced Ca(2+) transients, and the increase in I(Ca,L) induced by isoproterenol. These effects of SIN-1 were associated with an increased cGMP and a decreased cAMP content in ventricular myocytes in either the absence or presence of isoproterenol. These data suggest that the inhibitory effect of SIN-1 on basal and beta-adrenergic stimulated Ca2+ signal in ventricular myocytes could be due to the depression in the SR function and I(Ca,L), possibly mediated by a cGMP/cAMP-dependent mechanism. Taken together, the present study supports the idea that NO acts as an inhibitory modulator of the cardiac function during pathological conditions associated with an abnormal production of NO such as septic shock.

Effects of the aminopeptidase P inhibitor apstatin on bradykinin-induced inositol 1,4,5-triphosphate in neonatal rat cardiomyocytes

We investigated the effect of apstatin (an aminopeptidase P inhibitor) on bradykinin-induced inositol 1,4,5-triphosphate (IP3) formation and glucose uptake in isolated neonatal rat cardiomyocytes. Apstatin enhanced bradykinin-induced IP3 formation in a dose-dependent manner. We found that 1 microM Hoe 140 (a bradykinin B2-receptor antagonist) significantly decreased the potentiation of bradykinin-induced IP3 production by 5 microM apstatin from 781.8+/-67.2 to 127.4+/-33.0 pmol/mg protein; 5 microM apstatin increased bradykinin-induced glucose uptake from 197.0+/-25.5 to 297.3+/-64.0 pmol/h per milligram of protein. The stimulation of glucose uptake with apstatin was blocked to 132.5+/-26.2 pmol/h per milligram of protein by 1 microM Hoe 140. We conclude that apstatin stimulates bradykinin-induced IP3 formation and glucose uptake by preventing the degradation of bradykinin.

Altered baroreflex control of heart rate in bradykinin B2-receptor knockout mice

Recently, we have shown that a knockout mouse strain lacking the bradykinin B2-receptor gene exhibits an accelerated heart rate (HR) under basal conditions, this alteration being associated with mildly elevated blood pressure (BP) levels and ultimately with the development of cardiomyopathy. The goal of the present study was to determine whether genetic disruption of the B2-receptor alters autonomic cardiovascular reflexes to acute or chronic changes in BP. The direct mean BP and HR levels of unrestrained B2 knockout mice (B2-/-) were higher than those of wild type (B2+/+) controls (131 +/- 2 vs. 105 +/- 2 mm Hg and 480 +/- 5 vs. 414 +/- 8 beats/min, P < 0.01 for both comparisons). The difference in HR observed between groups under basal conditions was nullified by the acute administration of propranolol and atropine as well as by hexamethonium; it was attenuated by long-term blockade of angiotensin AT1 receptors. In B2-/- mice, the presence of an alteration in baroreceptor regulation of HR was supported by a reduced gain in the HR responses to acute nitroprusside-induced hypotension or phenylephrine-induced hypertension (slope of the regression line: 0.82 +/- 0.07 vs. 5.58 +/- 0.08 beats/min per mmHg in B2+/+, P < 0.01), as well as by an exaggerated tachycardic response to chronic hypertension induced by clipping of the left renal artery (60 +/- 3 vs. 15 +/- 3 beats/min in B2+/+, P < 0.01). Our findings indicate that disruption of the bradykinin B2-receptor gene is associated with an impaired baroreflex control of HR. The combination of chronically elevated resting HR and impaired baroreflex control could contribute to the development of cardiomyopathy in these animals.

Wall stress-induced dysrhythmias in the isolated working rat heart perfused through a cannula placed in the left ventricle via aorta

The purpose of the present study was to determine if our recently introduced novel working rat heart preparation could be used to study wall stress-induced dysrhythmias. A double cannula, which consisted of an outer cannula that, was inserted in the aorta and an inner cannula that was advanced into the left ventricle was used. The perfusion flowed through the inner cannula into the left ventricle and was ejected from there into the aorta. Afterload was changed suddenly from 60 to 160 Hg of pressure by turning a valve so that the fluid was diverted to a column set at a different height. A sudden increase of aortic pressure that lasted for 10 sec caused cardiac ectopic beats. Wall stress-induced dysrhythmias were more sustained during perfusion with low potassium and low magnesium Krebs-Henseleit solution. Bradykinin (1 microg) or epinephrine (10 microg) was injected as a bolus via an in-line injection port placed at the inner cannula. Bradykinin significantly reduced the incidence of ectopic beats and epinephrine increased the incidence of nonsustained runs of VT. This "working" heart preparation is a convenient tool to study wall stress-induced dysrhythmias.

Pharmacology and cardiovascular implications of the kinin-kallikrein system

Kinins are peptide hormones that can exert a significant influence on the regulation of blood pressure and vascular tone due to their vasodilatatory, natriuretic and growth modulating activity. Their cardiovascular involvement in physiological and pathophysiological situations has been studied intensively since inhibitors for angiotensin I-converting enzyme and selective receptor antagonists have become available for pharmacologically potentiating or inhibiting kinin-mediated reactions. Molecular biological analysis and the establishment of genetically modified animal models have also allowed newer information to be acquired on this subject. In this review, the components and cardiovascularly relevant mechanisms of the kinin-kallikrein system shall be described. Organ-specific effects concerning the kidneys, the vascular system, the heart and nervous tissue shall also be illustrated. On this issue, the physiological functions and pathophysiological implications of the kinin-kallikrein system should be clearly distinguished from the many, mostly endothelium-mediated protective effects which occur during ACE inhibition due to the potentiation of kinin effects. Finally, a view shall also be cast upon newly discovered targets of action, which could be exploited for therapeutically altering the kinin-kallikrein system.

Inhibitors of the renin angiotensin system: implications for the anaesthesiologist

The major long-term benefits of angiotensin-converting enzyme (ACE) inhibitors have now clearly been demonstrated in patients with arterial hypertension, cardiac insufficiency, coronary artery disease and several renal diseases. Such long-term treatment markedly alters the cardiovascular response to anaesthesia and surgery, whereas preliminary data suggest that short-term renin angiotensin system blockade might provide perioperative organ protection and improved circulatory conditions. Besides the classic view that the conversion of angiotensin I to angiotensin II is mainly due to ACE, alternative pathways have recently been identified, including cathepsin G as well as chymostatin- and aprotinin-sensitive serine proteases that are released from mastocytes and endothelial cells and which are insensitive to the effects of ACE inhibitors. These proteases are thought to contribute to tissue perfusion under hypoxic conditions and to structural remodelling. In clinical practice, ACE inhibitors may be preferred to angiotensin II receptor antagonists since the former, besides reducing angiotensin II synthesis, also lead to an accumulation of kinins (e.g. bradykinin), which have important cardio- and renal protective effects through liberation of prostacyclin and nitric oxide in endothelial cells and through stimulation of guanylate cyclase to form cyclic GMP.