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Severino P, D’Amato A, Prosperi S, Myftari V, Labbro Francia A, Önkaya M, Notari C, Papisca I, Canuti ES, Yarden Revivo M, Birtolo LI, Celli P, Galardo G, Maestrini V, d’Ettorre G, Mancone M, Fedele F. The Mutual Relationship among Cardiovascular Diseases and COVID-19: Focus on Micronutrients Imbalance. Nutrients 2022; 14:3439. [PMID: 36014944 PMCID: PMC9416353 DOI: 10.3390/nu14163439] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/12/2022] [Accepted: 08/15/2022] [Indexed: 12/16/2022] Open
Abstract
Micronutrients are ions and vitamins humbly required by the human body. They play a main role in several physiological mechanisms and their imbalance is strongly associated with potentially-fatal complications. Micronutrient imbalance is associated with many cardiovascular diseases, such as arrythmias, heart failure, and ischemic heart disease. It has been also observed in coronavirus disease 2019 (COVID-19), particularly in most severe patients. The relationship between cardiovascular diseases and COVID-19 is mutual: the latter triggers cardiovascular disease onset and worsening while patients with previous cardiovascular disease may develop a more severe form of COVID-19. In addition to the well-known pathophysiological mechanisms binding COVID-19 and cardiovascular diseases together, increasing importance is being given to the impact of micronutrient alterations, often present during COVID-19 and able to affect the balance responsible for a good functioning of the cardiovascular system. In particular, hypokalemia, hypomagnesemia, hyponatremia, and hypocalcemia are strongly associated with worse outcome, while vitamin A and D deficiency are associated with thromboembolic events in COVID-19. Thus, considering how frequent the cardiovascular involvement is in patients with COVID-19, and how it majorly affects their prognosis, this manuscript provides a comprehensive review on the role of micronutrient imbalance in the interconnection between COVID-19 and cardiovascular diseases.
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Affiliation(s)
- Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Andrea D’Amato
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Silvia Prosperi
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Vincenzo Myftari
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Aurora Labbro Francia
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Merve Önkaya
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Claudia Notari
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Ilaria Papisca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Elena Sofia Canuti
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Mia Yarden Revivo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Lucia Ilaria Birtolo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Paola Celli
- Anesthesiology and Intensive Care Unit, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
| | - Gioacchino Galardo
- Medical Emergency Unit, Sapienza University of Rome, Policlinico Umberto I, 00185 Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Gabriella d’Ettorre
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Francesco Fedele
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
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Tang CF, Ding H, Jiao RQ, Wu XX, Kong LD. Possibility of magnesium supplementation for supportive treatment in patients with COVID-19. Eur J Pharmacol 2020; 886:173546. [PMID: 32931782 PMCID: PMC7486870 DOI: 10.1016/j.ejphar.2020.173546] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/30/2020] [Accepted: 09/08/2020] [Indexed: 12/16/2022]
Abstract
Magnesium as an enzymatic activator is essential for various physiological functions such as cell cycle, metabolic regulation, muscle contraction, and vasomotor tone. A growing body of evidence supports that magnesium supplementation (mainly magnesium sulfate and magnesium oxide) prevents or treats various types of disorders or diseases related to respiratory system, reproductive system, nervous system, digestive system, and cardiovascular system as well as kidney injury, diabetes and cancer. The ongoing pandemic coronavirus disease 19 (COVID-19) characterized by respiratory tract symptoms with different degrees of important organ and tissue damages has attracted global attention. Particularly, effective drugs are still lacking in the COVID-19 therapy. In this review, we find and summarize the effectiveness of magnesium supplementation on the disorders or diseases, and provide a reference to the possibility of magnesium supplementation for supportive treatment in patients with COVID-19.
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Affiliation(s)
- Chuan-Feng Tang
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, 210023, People's Republic of China
| | - Hong Ding
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, 210023, People's Republic of China
| | - Rui-Qing Jiao
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, 210023, People's Republic of China
| | - Xing-Xin Wu
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, 210023, People's Republic of China
| | - Ling-Dong Kong
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, 210023, People's Republic of China.
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3
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Shah NC, Shah GJ, Li Z, Jiang XC, Altura BT, Altura BM. Short-term magnesium deficiency downregulates telomerase, upregulates neutral sphingomyelinase and induces oxidative DNA damage in cardiovascular tissues: relevance to atherogenesis, cardiovascular diseases and aging. Int J Clin Exp Med 2014; 7:497-514. [PMID: 24753742 PMCID: PMC3992387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 02/27/2014] [Indexed: 06/03/2023]
Abstract
1) short-term dietary deficiency of magnesium (Mg; 21 days) in rats (MgD) would result in a downregulation of telomerase in cardiac and aortic smooth muscle cells, 2) low levels of Mg(2+) added to drinking water (DW) would either prevent or greatly reduce the downregulation of telomerase in MgD, 3) MgD in rats would cause an upregulation of neutral-sphingomyelinase (N-SMAse) and p53, 4) short-term MgD would result in oxidation of DNA in diverse cardiac muscle and aortic smooth muscle cells as exemplified by measurement of 8-hydroxydeoxyguanosine (8-OH-dG), and 5) cross-talk between telomerase, N-SMase, p53, and 8-OH-dG would be evident in left ventricular (LV), right ventricular (RV), atrial and aortic smooth muscle obtained from rats subjected to short-term MgD. The data indicated that short-term MgD (10% normal dietary intake) resulted in downregulation of telomerase in LV, RV, atrial and aortic muscle cells; even very low levels of water-bourne Mg(2+) (e.g., 15-40 mg/lday) either prevented or ameliorated the downregulation of telomerase. Our experiments also showed that MgD resulted in a 7-10 fold increased formation of 8-OH-dG in the cardiac and aortic muscle cells. The experiments also confirmed that short-term dietary deficiency of Mg resulted in greatly increased upregulation of N-SMAse and p53 in the cardiac and aortic muscle tissues. These new experiments point to a sizeable cross-talk among telomerase, N-SMAse, and p53 in rat cardiac and peripheral vascular muscle exposed to a short-term MgD. These studies would be compatible with the idea that even short-term MgD could cause alterations of the genome in diverse cell types leading to mutations of cardiac, vascular, and endothelial cells seen in aging and atherogenesis. Since we have shown, previously, that activation of N-SMAse in MgD leads to synthesis and release of ceramide in cardiovascular tissues and cells, we believe this pathway, most likely, helps to result in downregulation of telomerase, upregulation of transcription factors (e.g., p53; NF-kB), cytokine release, mutations, transformations, and dysfunctional growth seen in the cardiac and vascular cells observed in the normal aging process, atherogenesis, hypertension, and cardiac failure. Lastly, we suggest ways in which this hypothesis can be tested.
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Affiliation(s)
- Nilank C Shah
- Department of Physiology and Pharmacology, State University of New York Downstate Medical CenterBrooklyn, NY 11203
| | - Gatha J Shah
- Department of Physiology and Pharmacology, State University of New York Downstate Medical CenterBrooklyn, NY 11203
| | - Zhiqiang Li
- Department of Anatomy and Cell Biology, State University of New York Downstate Medical CenterBrooklyn, NY 11203
| | - Xian-Cheng Jiang
- Department of Anatomy and Cell Biology, State University of New York Downstate Medical CenterBrooklyn, NY 11203
- The Center for Cardiovascular and Muscle Research, State University of New York Downstate Medical CenterBrooklyn, NY 11203
| | - Bella T Altura
- Department of Physiology and Pharmacology, State University of New York Downstate Medical CenterBrooklyn, NY 11203
- The Center for Cardiovascular and Muscle Research, State University of New York Downstate Medical CenterBrooklyn, NY 11203
- Bio-Defense Systems, Inc.Rockville Centre, NY 11570
| | - Burton M Altura
- Department of Physiology and Pharmacology, State University of New York Downstate Medical CenterBrooklyn, NY 11203
- The Center for Cardiovascular and Muscle Research, State University of New York Downstate Medical CenterBrooklyn, NY 11203
- Department of Medicine, State University of New York Downstate Medical CenterBrooklyn, NY 11203
- Bio-Defense Systems, Inc.Rockville Centre, NY 11570
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Drapkina OM, Gegnava BB. [Magnesium deficiency in cardiology]. TERAPEVT ARKH 2014; 86:104-6. [PMID: 25804050 DOI: 10.17116/terarkh20148612104-106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The paper considers the consequences and causes of magnesium deficiency in patients with cardiovascular diseases. The features of magnesium metabolism in atherosclerosis, hypertension, and heart failure are described. Prospects of magnesium therapy in cardiology practice are discussed.
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5
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Yang Y, Wu Z, Chen Y, Qiao J, Gao M, Yuan J, Nie W, Guo Y. Magnesium Deficiency Enhances Hydrogen Peroxide Production and Oxidative Damage in Chick Embryo Hepatocyte In Vitro. Biometals 2006; 19:71-81. [PMID: 16502333 DOI: 10.1007/s10534-005-6898-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2005] [Accepted: 05/04/2005] [Indexed: 10/25/2022]
Abstract
Magnesium deficiency and oxidative stress have been identified as correlative factors in many diseases. The origin of free radicals correlated with oxidative damage resulting from Mg-deficiency is unclear at the cellular level. To investigate whether hydrogen peroxide (H2O2) is associated in the oxidative stress induced by Mg-deficiency, the effect of Mg2+ deficiency (0, 0.4, 0.7 mM) on the metabolism of H2O2 was investigated in cultured chick embryo hepatocytes. After being cultured in the media with various concentrations of Mg2+ for 1, 2, 4, 6 and 10 days, parameters of H2O2 production, catalase activity, lipid peroxidation, intracellular total Mg and cell viability were analyzed. Results demonstrated that long-term incubation of chick embryo hepatocyte in extracellular Mg2+-deprivative and Mg2+-deficient (0.4 mM) states significantly enhanced the production of H2O2 (approximately twofold, respectively) and lipid peroxidation in the cell cultures, while decreasing the cell viability. Additionally, the reversing action of Mg2+ re-added to 1.0 mM and the partial reversing action of dimethylthiourea suggested that (i) [Mg2+]e deficiency induced the increase of H2O2 production, (ii) [Mg2+]e deficiency decreased catalase activity in chick embryo hepatocyte in vitro, subsequently causing oxidative stress and cell peroxidative damage.
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Affiliation(s)
- Ying Yang
- Division of Animal Nutrition and Feed Science, College of Animal Science and Technology, China Agricultural University (CAU), Beijing, 100094, P.R. China
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6
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Li J, Li W, Liu W, Altura BT, Altura BM. Mechanisms of hydroxyl radical-induced contraction of rat aorta. Eur J Pharmacol 2004; 499:171-8. [PMID: 15363964 DOI: 10.1016/j.ejphar.2004.07.094] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2004] [Revised: 07/16/2004] [Accepted: 07/20/2004] [Indexed: 11/19/2022]
Abstract
The present study was designed to investigate the effects of hydroxyl radicals (*OH), generated via the Fe2+-mediated Fenton reaction, on isolated rat aortic rings with and without endothelium. In the absence of any vasoactive agent, generation of *OH alone elicited an endothelium-independent contraction in rat aortic rings in a concentration-dependent manner. Hydroxyl radical-induced contractions of denuded rat aortic rings appeared, however, to be slightly stronger than those on intact rat aortic rings. The contractile responses to *OH were neither reversible nor reproducible in the same ring; even small concentrations of *OH radicals resulted in tachyphylaxis. Removal of extracellular calcium ions (Ca2+) or buffering intracellular Ca2+ with 10 microM acetyl methyl ester of bis(o-aminophenoxy) ethane-N,N,N',N',-tetraacetic acid (BAPTA-AM) significantly attenuated the contractile actions of *OH radicals. The presence of 1 microM staurosporine, 1 microM bisindolylmaleimide I, 1 microM Gö6976 [inhibitor of protein kinase C (PKC)], 2 microM PD-980592 (inhibitor of ERK), 10 microM genistein, and 1 microM wortmannin significantly inhibited the contractions induced by *OH. Proadifen (10 microM), on the other hand, significantly potentiated the hydroxyl radical-induced contractions. Exposure of primary cultured aortic smooth muscle cells to *OH produced significant, rapid rises of intracellular free Ca2+ ([Ca2+]i). Several, specific antagonists of possible endogenously formed vasoconstrictors did not inhibit or attenuate either hydroxyl radical-induced contractions or the elevation of [Ca2+]i. Our new results suggest that hydroxyl radical-triggered contractions on rat aortic rings are Ca2+-dependent. Several intracellular signal transduction systems seem to play some role in hydroxyl radical-induced vasoconstriction of rat aortic rings.
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MESH Headings
- Androstadienes/pharmacology
- Animals
- Aorta/drug effects
- Aorta/physiology
- Calcium/metabolism
- Calcium/pharmacology
- Carbazoles/pharmacology
- Cells, Cultured
- Cytochrome P-450 Enzyme Inhibitors
- Dose-Response Relationship, Drug
- Endothelium, Vascular/physiology
- Enzyme Inhibitors/pharmacology
- Ferrous Compounds/pharmacology
- Genistein/pharmacology
- Hydrogen Peroxide/pharmacology
- Hydroxyl Radical/pharmacology
- In Vitro Techniques
- Indoles/pharmacology
- Male
- Maleimides/pharmacology
- Mitogen-Activated Protein Kinases/antagonists & inhibitors
- Muscle, Smooth, Vascular/cytology
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/metabolism
- Phosphoinositide-3 Kinase Inhibitors
- Proadifen/pharmacology
- Protein Kinase C/antagonists & inhibitors
- Protein-Tyrosine Kinases/antagonists & inhibitors
- Rats
- Rats, Wistar
- Staurosporine/pharmacology
- Vasoconstriction/drug effects
- Wortmannin
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Affiliation(s)
- Jianfeng Li
- Department of Physiology and Pharmacology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203-2056, USA
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7
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Maier JAM, Malpuech-Brugère C, Zimowska W, Rayssiguier Y, Mazur A. Low magnesium promotes endothelial cell dysfunction: implications for atherosclerosis, inflammation and thrombosis. Biochim Biophys Acta Mol Basis Dis 2004; 1689:13-21. [PMID: 15158909 DOI: 10.1016/j.bbadis.2004.01.002] [Citation(s) in RCA: 171] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2003] [Revised: 01/05/2004] [Accepted: 01/06/2004] [Indexed: 01/08/2023]
Abstract
Because (i). endothelial cells are important players in cardiovascular diseases and (ii). Mg deficiency promotes atherosclerosis, thrombosis and hypertension, we evaluated whether low concentrations of Mg could directly affect endothelial behavior. We found that low Mg concentrations reversibly inhibit endothelial proliferation, and this event correlates with a marked down-regulation of the levels of CDC25B. The inhibition of endothelial proliferation is due to an up-regulation of interleukin-1 (IL-1), since an antisense oligonucleotide against IL-1 could prevent the growth inhibition observed in cells exposed to low concentrations of the cation. We also report the up-regulation of Vascular Cell Adhesion Molecule-1 (VCAM) and Plasminogen Activator Inhibitor (PAI)-1 after Mg deficiency. VCAM is responsible, at least in part, of the increased adhesion of monocytoid U937 cells to the endothelial cells grown in low magnesium. In addition, endothelial migratory response is severely impaired. By cDNA array, we identified several transcripts modulated by exposure to low Mg, some of which-c-src, ezrin, CD9, cytohesin and zyxin-contribute to endothelial adhesion to substrates and migration. In conclusion, our results demonstrate a direct role of low magnesium in promoting endothelial dysfunction by generating a pro-inflammatory, pro-thrombotic and pro-atherogenic environment that could play a role in the pathogenesis cardiovascular disease.
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Affiliation(s)
- Jeanette A M Maier
- Department of Preclinical Sciences LITA Vialba, University of Milan, Via GB Grassi 74, 20157, Milan, Italy.
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8
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Abstract
Endothelial cells (EC) form a unique signal-transducing surface in the vascular system. The abundance of ion channels in the plasma membrane of these nonexcitable cells has raised questions about their functional role. This review presents evidence for the involvement of ion channels in endothelial cell functions controlled by intracellular Ca(2+) signals, such as the production and release of many vasoactive factors, e.g., nitric oxide and PGI(2). In addition, ion channels may be involved in the regulation of the traffic of macromolecules by endocytosis, transcytosis, the biosynthetic-secretory pathway, and exocytosis, e.g., tissue factor pathway inhibitor, von Willebrand factor, and tissue plasminogen activator. Ion channels are also involved in controlling intercellular permeability, EC proliferation, and angiogenesis. These functions are supported or triggered via ion channels, which either provide Ca(2+)-entry pathways or stabilize the driving force for Ca(2+) influx through these pathways. These Ca(2+)-entry pathways comprise agonist-activated nonselective Ca(2+)-permeable cation channels, cyclic nucleotide-activated nonselective cation channels, and store-operated Ca(2+) channels or capacitative Ca(2+) entry. At least some of these channels appear to be expressed by genes of the trp family. The driving force for Ca(2+) entry is mainly controlled by large-conductance Ca(2+)-dependent BK(Ca) channels (slo), inwardly rectifying K(+) channels (Kir2.1), and at least two types of Cl( -) channels, i.e., the Ca(2+)-activated Cl(-) channel and the housekeeping, volume-regulated anion channel (VRAC). In addition to their essential function in Ca(2+) signaling, VRAC channels are multifunctional, operate as a transport pathway for amino acids and organic osmolytes, and are possibly involved in endothelial cell proliferation and angiogenesis. Finally, we have also highlighted the role of ion channels as mechanosensors in EC. Plasmalemmal ion channels may signal rapid changes in hemodynamic forces, such as shear stress and biaxial tensile stress, but also changes in cell shape and cell volume to the cytoskeleton and the intracellular machinery for metabolite traffic and gene expression.
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Affiliation(s)
- B Nilius
- Department of Physiology, KU Leuven, Campus Gasthuisberg, Leuven, Belgium.
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9
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Laurant P, Touyz RM. Physiological and pathophysiological role of magnesium in the cardiovascular system: implications in hypertension. J Hypertens 2000; 18:1177-91. [PMID: 10994748 DOI: 10.1097/00004872-200018090-00003] [Citation(s) in RCA: 116] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Attention is growing for a potential role of magnesium in the pathoetiology of cardiovascular disease. Magnesium modulates mechanical, electrical and structural functions of cardiac and vascular cells, and small changes in extracellular magnesium levels and/or intracellular free magnesium concentration may have significant effects on cardiac excitability and on vascular tone, contractility and reactivity. Thus, magnesium may be important in the physiological regulation of blood pressure whereas alterations in cellular magnesium metabolism could contribute to the pathogenesis of blood pressure elevation. Although most epidemiological and experimental studies support a pathological role for magnesium in the etiology and development of hypertension, data from clinical studies have been less convincing. Furthermore, the therapeutic value of magnesium in the management of essential hypertension is unclear. The present review discusses the molecular, biochemical, physiological and pharmacological roles of magnesium in the regulation of vascular function and blood pressure and introduces novel concepts relating to magnesium as a second messenger in intracellular signaling in cardiovascular cells. In addition, alterations in magnesium regulation in experimental and clinical hypertension and the potential antihypertensive therapeutic effects of magnesium are addressed.
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Affiliation(s)
- P Laurant
- Laboratoire Physiologie, Pharmacologie et Nutrition Prèventive Expérimentale, UFR Médecine et Pharmacie, Université de Franche-Comté, Besancon, France
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10
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Altura BM, Altura BT. Association of alcohol in brain injury, headaches, and stroke with brain-tissue and serum levels of ionized magnesium: a review of recent findings and mechanisms of action. Alcohol 1999; 19:119-30. [PMID: 10548155 DOI: 10.1016/s0741-8329(99)00025-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Although there is general agreement that chronic ingestion of alcohol poses great risks for normal cardiovascular functions and peripheral-vascular homeostasis, a direct cause and effect between the real phenomena of alcohol-induced headache and risk of brain injury and stroke is not appreciated. "Binge drinking" of alcohol is associated with an ever-growing number of strokes and sudden death. It is becoming clear that alcohol ingestion can result in profoundly different actions on the cerebral circulation (e.g., vasodilation, vasoconstriction-spasm, vessel rupture), depending upon dose and physiologic state of host. Using rats, it has been demonstrated that acute, high doses of ethanol can result in stroke-like events concomitant with alterations in brain bioenergetics. We review recent in vivo findings obtained with 31P-NMR spectroscopy, optical reflectance spectroscopy, and direct in vivo microcirculatory studies on the intact brain. Alcohol-induced hemorrhagic stroke is preceded by a rapid fall in brain intracellular free magnesium ions ([Mg2+]i) followed by cerebrovasospasm and reductions in phosphocreatine (PCr)/ATP ratio, intracellular pH, and the cytosolic phosphorylation potential (CPP) with concomitant rises in deoxyhemoglobin (DH), mitochondrial reduced cytochrome oxidase aa3 (rCOaa3), blood volume, and intracellular inorganic phosphate (Pi). Using osmotic mini-pumps implanted in the third cerebral ventricle, containing 30% ethanol, it was found that brain [Mg2+]i is reduced 30% after 14 days; brain PCr fell 15%, whereas the CPP fell 40%. Such animals became susceptible to stroke from nonlethal doses of ethanol. Human subjects with mild head injury have been found to exhibit early deficits in serum ionized Mg (IMg2+); the greater the degree of early head injury (30 min-8 h), the greater and more profound the deficit in serum IMg2+ and the greater the ionized Ca (ICa2+) to IMg2+ ratio. Patients with histories of alcohol abuse or ingestion of alcohol prior to head injury exhibited greater deficits in IMg2+ (and higher ICa2+/IMg2+ ratios) and, unlike the subjects without alcohol, did not leave the hospital for at least several days. Women, for some unknown reason, exhibit a much higher incidence of morbidity and mortality from subarachnoid hemorrhage (SAH) than men. Data on 105 men and women with different types of stroke indicate that, on the average, a 20% deficit in serum IMg2+ is seen; total Mg (TMg) or blood pH is usually near normal. Women with SAH, however, exhibit much lower IMg2+ and higher ICa2+/IMg2+ ratios; the presence of ethanol in the blood is associated with even more depression in IMg2+ in SAH in women. It is possible that prior alcohol ingestion is, in large measure, responsible for a great deal of this unexplained higher incidence of SAH in women. It has recently been reported that the cyclical changes in estrogenic hormones appear to control the serum IMg2+ level in young women. A surge in estrogenic levels prior to SAH could thus precipitate, in part, the SAH. In other human studies, it has been shown that migraines and headache, dizziness, and hangover, which accompany ethanol ingestion, are associated with rapid deficits in serum IMg2+ but not in TMg. The former, and the alcohol-associated headache, can be ameliorated with IV administration of MgSO4. Premenstrual tension-headache (PTH) and its exacerbation by alcohol in women is also accompanied by deficits in IMg2+, and elevation in serum ICa2+/IMg2+; IV MgSO4 corrects the PTH and the serum deficit in IMg2+. Animal experiments show that IV Mg2+ can prevent alcohol-induced hemorrhagic stroke and the subsequent fall in brain [Mg2+]i, [PCr], pHi, and CPP. Other recent data indicate that alcohol-induced cellular loss of [Mg2+]i is associated with cellular Ca2+ overload and generation of oxygen-derived free radicals; chronic pretreatment with vitamin E prevents alcohol-induced vascular injury and pathology in the brain. (ABSTRACT TRUNCATED)
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Affiliation(s)
- B M Altura
- Department of Physiology, State University of New York, Health Science Center at Brooklyn, 11203, USA
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11
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Li W, Zheng T, Wang J, Altura BT, Altura BM. Methanol elevates cytosolic calcium ions in cultured canine cerebral vascular smooth muscle cells: possible relation to CNS toxicity. Alcohol 1999; 18:221-4. [PMID: 10456574 DOI: 10.1016/s0741-8329(99)00007-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Acute exposure of cultured canine cerebral vascular smooth muscle cells to methanol (10-400 mM) results in concentration-dependent elevation of the concentration of intracellular free calcium ion ([Ca2+]i) as measured with the fluorescent indicator, fura-2, and digital imaging microscopy. The resting level of [Ca2+]i in the cerebral vascular smooth muscle cells was 89.3+/-5.3 nM. Exposure of these cells to 10 mM methanol for only 5 min resulted in significant elevation in [Ca2+]i (i.e., to 105.7+/-4.6) (p < 0.05). Methanol (10 mM) is a concentration found in the blood of victims demonstrating early CNS toxicity. Other, higher concentrations of methanol rapidly raised [Ca2+]i upwards of 60% over basal resting levels. These result suggest that methanol-induced cerebral vasospasm is a consequence of large rises in intracellular Ca2+. These events could play a crucial role in methanol-induced cerebral edema, brain hemorrhage, and cerebral and retinal infarcts, eventuating in severe deficits in brain blood flow and the known, subsequent CNS disturbances.
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Affiliation(s)
- W Li
- Department of Physiology, State University of New York, Health Science Center at Brooklyn, 11203, USA
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12
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Altura BM, Gebrewold A. Pyrrolidine dithiocarbamate attenuates alcohol-induced leukocyte-endothelial cell interaction and cerebral vascular damage in rats: possible role of activation of transcription factor NF-kappaB in alcohol brain pathology. Alcohol 1998; 16:25-8. [PMID: 9650633 DOI: 10.1016/s0741-8329(97)00166-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Effects of chronic (14-day) pretreatment of orally administered pyrrolidine dithiocarbamate (PDTC) (100 or 200 mg/kg/day) on alcohol-induced venular cerebrovasospasm, microvessel rupture, leukocyte-endothelial chemoattraction, and microhemorrhaging was studied by direct, quantitative in vivo high-resolution TV microscopy of the intact rat brain. Sham animals chronically treated with placebo exhibited concentration-dependent venular cerebrovasospasm, endothelial-leukocyte rolling and attraction, microvessel rupture. and focal hemorrhages, irrespective of route (i.e., perivascular, systemic) of ethanol administration. PDTC pretreatment either prevented or ameliorated greatly the cerebrovasospasm, leukocyte-endothelial chemoattraction, and brain vascular damage induced by ethanol. These new data suggest that alcohol induces cerebral vascular and brain damage by reperfusion injury events, which trigger induction of proinflammatory factors, and transcription factor NF-kappaB and lipid peroxidation of vascular smooth muscle and endothelial cell membranes; these proinflammatory, pro-oxidant, and redox events could play a crucial role in the pathogenesis of alcohol-induced cerebral ischemia and stroke.
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Affiliation(s)
- B M Altura
- Department of Physiology, The Center for Cardiovascular and Muscle Research, State University of New York, Health Science Center at Brooklyn, 11203, USA
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13
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Li HY, Quamme GA. Caffeine decreases intracellular free Mg2+ in isolated adult rat ventricular myocytes. BIOCHIMICA ET BIOPHYSICA ACTA 1997; 1355:61-8. [PMID: 9030202 DOI: 10.1016/s0167-4889(96)00117-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Caffeine has been extensively used to study intracellular Ca2+ control and contraction-relaxation in cardiomyocytes. The effects of caffeine on intracellular free Mg2+ concentration, [Mg2+]i, were studied in isolated adult rat ventricular myocytes by fluorescent techniques using mag-fura-2. Basal [Mg2+]i was 0.62 +/- 0.02 mM, n = 54, in quiescent cells and 0.73 +/- 0.02 mM, n = 23, in electrically-stimulated adult rat ventricular myocytes. Caffeine, 20 mM, significantly decreased [Mg2+] in both quiescent (-0.17 +/- 0.01 mM) and electrically-stimulated (-0.16 +/- 0.01 mM) adult ventricular myocytes. Ryanodine, a blocker for Ca(2+)-release channels of the sarcoplasmic reticulum, did not have any effect on basal [Mg2+]i, 0.67 +/- 0.02 mM nor on caffeine-induced reduction in [Mg2+]i, -0.16 +/- 0.01 mM in quiescent cardiomyocytes or electrically-stimulated cells; 0.74 +/- 0.03 mM and -0.11 +/- 0.03 mM, respectively. Ruthenium red, an inhibitor of mitochondrial Ca2+ uptake, also failed to alter basal [Mg2+]i, or caffeine-induced reduction in [Mg2+], in either quiescent or electrically-stimulated cells. The effects of caffeine on [Mg2+]i, may be important in considering the use of this drug to study contraction/function studies in heart cells.
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Affiliation(s)
- H Y Li
- Department of Medicine, University of British Columbia, Vancouver Hospital, Canada
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14
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Altura BM, Gebrewold A. alpha-Tocopherol attenuates alcohol-induced cerebral vascular damage in rats: possible role of oxidants in alcohol brain pathology and stroke. Neurosci Lett 1996; 220:207-10. [PMID: 8994229 DOI: 10.1016/s0304-3940(96)13268-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Effects of chronic (14 day) pretreatment of timed-release of alpha-tocopherol (approximately 1.25-5 mg/day) on alcohol-induced venular cerebrovasospasm, microvessel rupture and micro-hemorrhaging was studied by direct, quantitative in-vivo high-resolution TV microscopy of the intact rat brain. Sham animals chronically treated with placebo exhibited concentration-dependent venular cerebrovasospasm, microvessel rupture and focal hemorrhages, irrespective of route (i.e. perivascular, systemic) of ethanol administration. alpha-Tocopherol pretreatment either prevented or ameliorated greatly the cerebrovasospasm and vascular damage induced by ethanol. These results suggest that alcohol-induced cerebral vascular and brain damage by reperfusion injury events triggers lipid peroxidation of vascular smooth muscle and endothelial cell membranes; these pro-oxidant events could play a crucial role in the pathogenesis of alcohol-induced cerebral ischemia and stroke.
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Affiliation(s)
- B M Altura
- Department of Physiology, SUNY Health Science Center at Brooklyn 11203, USA
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15
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Delpiano MA, Altura BM. Modulatory effect of extracellular Mg2+ ions on K+ and Ca2+ currents of capillary endothelial cells from rat brain. FEBS Lett 1996; 394:335-9. [PMID: 8830669 DOI: 10.1016/0014-5793(96)00980-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Using whole-cell patch-clamp recording, we demonstrate that exposure of single rat brain capillary endothelial cells to different extracellular Mg2+ concentrations (0.3, 4.8 and 9.6 mM) affects the conductance of K+ and Ca2+ currents elicited under control conditions (1.2 mM). Extracellular Mg2+ concentrations ([Mg2+]o) of 4.8 and 9.6 mM reversibly depress outward K+ currents by about 30 +/- 12% (n = 10) and 34 +/- 13% (n = 10), at all activating potentials, respectively. Using identical concentrations reversibly depressed the Ca2+ current by about 40 +/- 16% (n = 8) and 46 +/- 18% (n = 6), respectively. Using a low Mg2+ concentration of 0.3 mM, the K+ current activation was unexpectedly and mildly increased by about 15 +/- 5% (n = 5), and the inward Ca2+ current was attenuated. When studying this effect of low [Mg2+]o on 'pure' Ca2+ currents, free of outward currents, we found that this inward current was depressed by about 38 +/- 16%(n = 8), and its threshold for activation, in the current-voltage relationship, was shifted to more negative potentials. It is concluded that high [Mg2+]o hinders the entry of Ca2+ through low-voltage activated Ca2+ channels and thereby attenuates a Ca2+-regulated K+ conductance. At a low [Mg2+]o (0.3 mM), Mg2+ shifts the steady-state inactivation of the voltage-activated Ca2+ channel to more negative potentials by about 8 mV (n = 6), probably due to a negative screening effect, i.e. a reduction of positive charges on the cell membrane. This may contribute to an apparent increase in K+ conductance by an, as yet, unknown mechanism.
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Affiliation(s)
- M A Delpiano
- Max-Planck-Institut für molekulare Physiologie, Dortmund, Germany
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Otun H, Aidulis DM, Yang JM, Gillespie JI. Interactions between inositol trisphosphate and Ca2+ dependent Ca2+ release mechanisms on the endoplasmic reticulum of permeabilised bovine aortic endothelial cells. Cell Calcium 1996; 19:315-25. [PMID: 8983852 DOI: 10.1016/s0143-4160(96)90072-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In this paper we describe data from cultured bovine aortic endothelial (BAE) cells demonstrating a Ca2+ induced Ca2+ release (CICR) process which appears to have pharmacological properties different from CICR mechanisms in other cell types. CICR was measured in saponin permeabilised cells in which the internal stores had been preloaded with 45Ca2+. Step increases in the free Ca2+ concentration of the bathing solution, from 10 nM up to 10 microM were found to increase 45Ca2+ loss. This process was completely inhibited by ruthenium red. Caffeine induced a small release of 45Ca2+ and the response to a subsequent stimulation with a Ca2+ step was reduced. In intact cells, ryanodine activated small oscillations in intracellular Ca2+ in the presence, but not the absence, of external Ca2+. However, in permeabilised cells, ryanodine had no effect on either basal efflux or the increased efflux of 45Ca2+ seen following a step increase in free Ca2+. These data suggest the operation of a ruthenium red sensitive but ryanodine insensitive CICR mechanism on the endoplasmic reticulum (ER) which may also be modulated by caffeine. An IP3 dependent 45Ca2+ release was also observed. In the presence of ruthenium red, the IP3 induced 45Ca2+ release was reduced suggesting that CICR may operate to amplify the magnitude of the IP3 response. The Ca2+ dependence of the IP3 induced release was also measured. Co-operativity between IP3 and Ca2+ could not be detected between 100-300 nM Ca2+. The results suggest that the regulation of IP3 induced Ca2+ release may be different in BAE cells, and point to the operation of a 'novel' CICR process and to complex interactions between Ca2+ release systems in BAE cells.
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Affiliation(s)
- H Otun
- Department of Obstetrics and Gynaecology, University of Newcastle, Newcastle upon Tyne, UK
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Delpiano MA, Altura BM. Transmembrane currents in capillary endothelial cells are modulated by external Mg2+ ions. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1996; 410:115-8. [PMID: 9030287 DOI: 10.1007/978-1-4615-5891-0_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- M A Delpiano
- Max-Planck-Institut für molekulare Physiology, Dortmund, Germany
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18
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Jino H, Kurahashi K, Usui H, Shirahase H, Nakata Y, Shimizu Y. Pharmacological natures of caffeine-induced endothelium-dependent and -independent contraction in canine mesenteric artery. Life Sci 1995; 57:1155-62. [PMID: 7674804 DOI: 10.1016/0024-3205(95)02061-m] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The present experiments were carried out to elucidate whether pharmacological nature of caffeine (1 mM)-induced endothelium-dependent contraction (EDC) is different from that of caffeine (10 mM)-induced endothelium-independent contraction (EIC) in canine mesenteric artery. Caffeine (1 mM)-induced EDC was abolished when arterial strips were incubated in Ca(++)-free medium for 20 min, but EIC was not abolished. EGTA and EDTA (0.5 and 1 mM) attenuated the EDC, and at the concentration of 2.5 mM completely abolished the EDC. Nifedipine (10(-6) and 3 x 10(-6) M), diltiazem (10(-6) M) and verapamil (10(-6) M) did not affect the caffeine (1 mM)-induced EDC. Lemakalim (10(-8), 3 x 10(-8) and 10(-7) M) attenuated the caffeine (1 mM)-induced EDC in a concentration-dependent manner. Lemakalim (10(-7) M) nearly abolished the EDC. The inhibitory effect of lemakalim (10(-7) M) on the EDC was antagonized in the presence of glibenclamide (3 x 10(-6) M). In contrast, caffeine (10 mM)-induced EIC was resistant to lemakalim at higher concentration (3 x 10(-7) M). Forskolin (10(-7), 3 x 10(-7) and 10(-6) M) significantly attenuated both the caffeine (1 mM)-induced EDC and caffeine (10 mM)-induced EIC. The inhibitory effect of forskolin on the EDC was augmented in the presence of rolipram (10(-6) M). Nitroglycerin (10(-5) M) attenuated significantly caffeine-induced both EDC and EIC. The inhibitory effect of nitroglycerin on the EDC was augmented in the presence of zaprinast (10(-5) M). The present experiments demonstrate that caffeine-induced EDC is due to nifedipine-resistant and lemakalim-sensitive Ca++ mobilization and the EIC is due to both nifedipine- and lemakalim-resistant Ca++ mobilization in canine mesenteric artery.
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Affiliation(s)
- H Jino
- Pharmacology Division, Kyoto University, Japan
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Rusko J, Wang X, van Breemen C. Regenerative caffeine-induced responses in native rabbit aortic endothelial cells. Br J Pharmacol 1995; 115:811-21. [PMID: 8548181 PMCID: PMC1908507 DOI: 10.1111/j.1476-5381.1995.tb15005.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
1. Single native aortic endothelial cells obtained by enzymatic dispersion of the rabbit aortic endothelium were held under voltage clamp using patch pipette and whole-cell membrane currents were measured. In parallel experiments performed on cells from the same batches, the free internal calcium concentration, [Ca2+]i, in the cell was estimated by use of the Ca(2+)-sensitive fluorescent dye, fura-2. 2. Caffeine (20 mM) applied to the cell evoked an outward current and an initial peak in [Ca2+]i followed by a lower sustained rise (plateau). Ca(2+)-free, EGTA-containing solution applied outside the cells did not reduce these responses. 3. Following caffeine stimulation there was a biphasic rising phase of outward current both in the presence and absence of extracellular Ca2+. 4. Application of graded doses of caffeine revealed all-or-none type responses of both the outward current and the rise in [Ca2+]i. 5. Preincubation with lower doses of caffeine reduced the magnitude of both the outward current and the [Ca2+]i transient evoked by 20 mM caffeine. 6. Tetraethylammonium (3 mM) applied to the bathing solution blocked unitary and spontaneous transient outward currents (STOCs) stimulated by Ca(2+)-free solution, but only reduced the outward current evoked by caffeine (20 mM). 7. In conclusion, our results reveal the all-or-none nature of Ca2+ release from the endoplasmic reticulum (ER) in native aortic endothelial cells. Lower concentrations of caffeine (0.4-0.5 mM) may deplete intracellular Ca2+ stores. Extracellular Ca2+ is not necessary for maintaining the activity of spontaneous and caffeine-induced outward currents in native aortic endothelial cells. Spontaneous outward currents are believed to represent the sporadic release of calcium from store sites independent of both extracellular Ca2+ and the caffeine-sensitive Ca2+ stores which stimulate the outward current.
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Affiliation(s)
- J Rusko
- Department of Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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Altura BM, Gebrewold A, Altura BT, Gupta RK. Role of brain [Mg2+]i in alcohol-induced hemorrhagic stroke in a rat model: a 31P-NMR in vivo study. Alcohol 1995; 12:131-6. [PMID: 7772264 DOI: 10.1016/0741-8329(94)00072-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
One hundred percent of anesthetized rats administered 6.6 gm/kg of ethanol IP died within 10-35 min of alcohol injection; upon autopsy of the brain all demonstrated profound subarachnoid and intracranial bleeding, clear signs of hemorrhagic stroke. Pretreatment of rats with 4 mumol/min MgCl2, but not saline, via IV administration (for 30-45 min), prevented hemorrhagic stroke in all animals so treated with 6.6 gm/kg ethanol. Administration of the stroke dose of alcohol resulted in rapid (within 3-5 min) and marked deficits in whole brain intracellular free Mg ([Mg2++]i) as observed by in vivo 31P-NMR spectroscopy. Intracellular pH (pHi) and the phosphocreatine [PCr]/[ATP] ratio also fell following a significant fall in brain [Mg2+]i). Brains of rats that exhibited strokelike events, upon death and autopsy, demonstrated continued and marked intracellular acidosis with progressive fall in the [PCr]/[ATP] ratio and elevation of inorganic phosphate (Pi) and [H+]i; these events were not accompanied by any rises in systemic arterial blood pressure. Rats pretreated with MgCl2 exhibited relatively stable brain [Mg2+]i, and essentially unchanged pHi, [PCr], [ATP], or [Pi] following alcohol administration, although such animals exhibited threefold alterations in plasma Mg2+, as measured by ion selective electrodes. These observations suggest that high alcohol ingestion can result in severe vasospasm, ischemia, and rupture of blood vessels probably as a consequence of depletion of brain [Mg2+]i, events that can be prevented by Mg2+ pretreatment.
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Affiliation(s)
- B M Altura
- Department of Physiology, State University of New York, Health Science Center at Brooklyn 11203, USA
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Naderali EK, Poyser NL. The effect of caffeine on prostaglandin output from the perfused mesenteric vascular bed of the rat. Prostaglandins Leukot Essent Fatty Acids 1994; 51:415-8. [PMID: 7708807 DOI: 10.1016/0952-3278(94)90058-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Caffeine significantly (p < 0.05) increased the output of prostacyclin (PGI2) from the perfused rat mesenteric vascular bed. The outputs of PGE2 and PGF2 alpha were also increased by caffeine. This stimulatory response to caffeine did not show rapid desensitization. Ryanodine also increased PG output, suggesting that caffeine may be acting via the stimulation of a ryanodine receptor. The increased production of a vasodilator such as PGI2 from blood vessels following exposure to caffeine may explain why caffeine has a beneficial effect in angina.
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Affiliation(s)
- E K Naderali
- Department of Pharmacology, University of Edinburgh Medical School, UK
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