Dissociation of exercise-induced pulmonary hemorrhage and pulmonary artery pressure via nitric oxide synthase inhibition

Howard H. Erickson: contributions to equine exercise physiology and veterinary medicine

For over four and a half decades Howard Erickson has been at the forefront of scientific discovery. As a veterinary cardiovascular specialist with the United States Air Force he made fundamental progress to developing a working artificial heart. Subsequently as a retired US Air Force Colonel and Professor at Kansas State University College of Veterinary Medicine Erickson detected the immensely high pulmonary vascular pressures in the horse during exercise. These observations were essential to resolving the mechanistic bases for exercise-induced arterial hypoxemia and pulmonary haemorrhage (EIPH) that afflict all racehorses. Subsequently, Erickson pioneered the scientific proof-of-concept of the equine Nasal Strip™ which reduces lung damage and epistaxis, and constitutes the only effective non-pharmaceutical treatment for EIPH available today. We owe much of our understanding of equine cardiorespiratory physiology to this remarkable scientist.

Highly athletic terrestrial mammals: horses and dogs

Evolutionary forces drive beneficial adaptations in response to a complex array of environmental conditions. In contrast, over several millennia, humans have been so enamored by the running/athletic prowess of horses and dogs that they have sculpted their anatomy and physiology based solely upon running speed. Thus, through hundreds of generations, those structural and functional traits crucial for running fast have been optimized. Central among these traits is the capacity to uptake, transport and utilize oxygen at spectacular rates. Moreover, the coupling of the key systems--pulmonary-cardiovascular-muscular is so exquisitely tuned in horses and dogs that oxygen uptake response kinetics evidence little inertia as the animal transitions from rest to exercise. These fast oxygen uptake kinetics minimize Intramyocyte perturbations that can limit exercise tolerance. For the physiologist, study of horses and dogs allows investigation not only of a broader range of oxidative function than available in humans, but explores the very limits of mammalian biological adaptability. Specifically, the unparalleled equine cardiovascular and muscular systems can transport and utilize more oxygen than the lungs can supply. Two consequences of this situation, particularly in the horse, are profound exercise-induced arterial hypoxemia and hypercapnia as well as structural failure of the delicate blood-gas barrier causing pulmonary hemorrhage and, in the extreme, overt epistaxis. This chapter compares and contrasts horses and dogs with humans with respect to the structural and functional features that enable these extraordinary mammals to support their prodigious oxidative and therefore athletic capabilities.

Effects of a specific endothelin-1A antagonist on exercise-induced pulmonary haemorrhage (EIPH) in thoroughbred horses

REASONS FOR PERFORMING STUDY

During high intensity exercise, the very high pulmonary artery pressure (Ppa) experienced by Thoroughbred horses is considered a major factor in the aetiology of exercise-induced pulmonary haemorrhage (EIPH). Recently, endothelin-1 (ET-1), a potent vasoconstrictive hormone, has been found to increase Ppa in horses at rest via binding to its ET-1A receptor subtype. In addition, plasma concentrations of ET-1 are increased in horses during and after high intensity exercise.

HYPOTHESIS

If ET-1 increases Ppa during exercise in the horse, administration of a specific ET-1A antagonist would decrease Ppa and therefore EIPH.

METHODS

Saline (CON) or an ET-1A receptor antagonist, TBC3214 (3 mg/kg bwt i.v.; ANTAG) was administered to horses 1 h prior to maximal incremental exercise on a high-speed treadmill. Gas exchange measurements were made breath-by-breath and blood samples collected during each 1 min stage to determine blood gases, acid-base status and cardiac output. EIPH was determined via bronchoalveolar lavage (BAL) approximately 30 min after exercise.

RESULTS

The time to fatigue, gas exchange and cardiovascular responses were not different between groups (P>0.05). Resting and peak Ppa did not differ significantly between treatments. Most importantly, ANTAG did not decrease EIPH.

CONCLUSIONS

These results do not support a deterministic role for ET-1 in the increased Ppa and therefore EIPH, during maximal exercise in the equine athlete.

POTENTIAL RELEVANCE

Treatment with an ET-1A receptor antagonist does not appear to be a viable therapeutic intervention in the prevention of EIPH.

Exercise-induced pulmonary hemorrhage

EIPH is a condition affecting virtually all horses during intense exercise worldwide. The hemorrhage originates from the pulmonary vasculature and is distributed predominantly bilaterally in the dorsocaudal lung lobes. As the condition progresses, the lung abnormalities extend cranially along the dorsal portions of the lung. An inflammatory response occurs in association with the hemorrhage and may contribute to the chronic sequela. Although conflicting opinions exist as to its affect on performance, it is a syndrome that is thought to increase in severity with age. The most commonly performed method to diagnose EIPH at the present time is endoscopy of the upper airway alone or in combination with tracheal wash analysis for the presence of erythrocytes and hemosiderophages. Because horses may not bleed to the same extent every time and the bleeding may originate from slightly different locations, these diagnostic procedures may not be extremely sensitive or quantitative. At this time, there is no treatment that is considered a panacea, and the currently allowed treatments have not proven to be effective in preventing EIPH. Future directions for therapeutic intervention may need to include limiting inflammatory responses to blood remaining within the lungs after EIPH.

NO inhalation reduces pulmonary arterial pressure but not hemorrhage in maximally exercising horses

In horses, the exercise-induced elevation of pulmonary arterial pressure (Ppa) is thought to play a deterministic role in exercise-induced pulmonary hemorrhage (EIPH), and thus treatment designed to lower Ppa might reasonably be expected to reduce EIPH. Five Thoroughbred horses were run on a treadmill to volitional fatigue (incremental step test) under nitric oxide (NO; inhaled 80 ppm) and control (N(2), same flow rate as per NO run) conditions (2 wk between trials; order randomized) to test the hypothesis that NO inhalation would reduce maximal Ppa but that this reduction may not necessarily reduce EIPH. Before each investigation, a microtipped pressure transducer was placed in the pulmonary artery 8 cm past the pulmonic valve to monitor Ppa. EIPH severity was assessed via bronchoalveolar lavage (BAL) 30 min postrun. Exercise time did not differ between the two trials (P > 0.05). NO administration resulted in a small but consistent and significant reduction in peak Ppa (N(2), 102.3 +/- 4.4; NO, 98.6 +/- 4.3 mmHg, P < 0.05). In the face of lowered Ppa, EIPH severity was significantly higher in the NO trial (N(2), 22.4 +/- 6.8; NO, 42.6 +/- 15.4 x 10(6) red blood cells/ml BAL fluid, P < 0.05). These findings support the notion that extremely high Ppa may reflect, in part, an arteriolar vasoconstriction that serves to protect the capillary bed from the extraordinarily high Ppa evoked during maximal exercise in the Thoroughbred horse. Furthermore, these data suggest that exogenous NO treatment during exercise in horses may not only be poor prophylaxis but may actually exacerbate the severity of EIPH.