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Tu W, Li L, Yi M, Chen J, Wang X, Sun Y. Dapagliflozin attenuates high glucose-and hypoxia/reoxygenation-induced injury via activating AMPK/mTOR-OPA1-mediated mitochondrial autophagy in H9c2 cardiomyocytes. Arch Physiol Biochem 2023:1-11. [PMID: 37655809 DOI: 10.1080/13813455.2023.2252200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/07/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Abstract
This study investigated the protective effect of dapagliflozin on H9c2 cardiomyocyte function under high glucose and hypoxia/reoxygenation (HG-H/R) conditions and identified the underlying molecular mechanisms. Dapagliflozin reduced the level of lactate dehydrogenase and reactive oxygen species in cardiomyocytes under HG-H/R conditions and was accompanied by a decrease in caspase-3/9 activity. In addition, Dapagliflozin significantly reduced mitochondrial permeability transition pore opening and increased ATP content, accompanied by upregulation of OPA1 with autophagy-related protein molecules and activation of the AMPK/mTOR signalling pathway in HG-H/R treated cardiomyocytes. OPA1 knockdown or compound C treatment attenuated the protective effects of dapagliflozin on the cardiomyocytes under HG-H/R conditions. Downregulation of OPA1 expression increased mitochondrial intolerance in cardiomyocytes during HG-H/R injury and the AMPK-mTOR-autophagy signalling is a key mechanism for protecting mitochondrial function and reducing cardiomyocyte apoptosis. Collectively, dapagliflozin exerted protective effects on the cardiomyocytes under HG-H/R conditions. Dapagliflozin attenuated myocardial HG-H/R injury by activating AMPK/mTOR-OPA1-mediated mitochondrial autophagy.
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Affiliation(s)
- Weiling Tu
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, P.R. China
| | - Liang Li
- Department of Cardiology, Shenzhen Bao'an Traditional Chinese Medicine Hospital, Guangzhou University of Chinese Medicine, Shenzhen, P.R. China
| | - Ming Yi
- Department of Cardiology, The Second Affiliated Integrated Chinese and Western Medicine Hospital of Hunan University of Chinese Medicine, Liuyang Hospital of Traditional Chinese Medicine, Liuyang, P.R. China
| | - Junyu Chen
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen Sun Yat-sen Cardiovascular Hospital, Shenzhen, P.R. China
| | - Xiaoqing Wang
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen Sun Yat-sen Cardiovascular Hospital, Shenzhen, P.R. China
| | - Yan Sun
- Department of Endocrinology, Southern University of Science and Technology Hospital, Shenzhen, P.R. China
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Hansen ESS, Tougaard RS, Nørlinger TS, Mikkelsen E, Nielsen PM, Bertelsen LB, Bøtker HE, Jørgensen HS, Laustsen C. Imaging porcine cardiac substrate selection modulations by glucose, insulin and potassium intervention: A hyperpolarized [1- 13 C]pyruvate study. NMR IN BIOMEDICINE 2017; 30. [PMID: 28186677 DOI: 10.1002/nbm.3702] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 12/21/2016] [Accepted: 12/30/2016] [Indexed: 05/07/2023]
Abstract
Cardiac metabolism has received considerable attention in terms of both diagnostics and prognostics, as well as a novel target for treatment. As human trials involving hyperpolarized magnetic resonance in the heart are imminent, we sought to evaluate the general feasibility of detection of an imposed shift in metabolic substrate utilization during metabolic modulation with glucose-insulin-potassium (GIK) infusion, and thus the limitations associated with this strategy, in a large animal model resembling human physiology. Four [1-13 C]pyruvate injections did not alter the blood pressure or ejection fraction over 180 min. Hyperpolarized [1-13 C]pyruvate conversion showed a generally high reproducibility, with intraclass correlation coefficients between the baseline measurements at 0 and 30 min as follows: lactate to pyruvate, 0.85; alanine to pyruvate, 1.00; bicarbonate to pyruvate, 0.83. This study demonstrates that hyperpolarized [1-13 C]pyruvate imaging is a feasible technique for cardiac studies and shows a generally high reproducibility in fasted large animals. GIK infusion increases the metabolic conversion of pyruvate to its metabolic derivatives lactate, alanine and bicarbonate, but with increased variability.
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Affiliation(s)
- Esben Søvsø Szocska Hansen
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Diabetes Academy, Odense, Denmark
| | - Rasmus Stilling Tougaard
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus N, Denmark
| | | | - Emmeli Mikkelsen
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Per Mose Nielsen
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lotte Bonde Bertelsen
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus N, Denmark
| | | | - Christoffer Laustsen
- MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Abstract
BACKGROUND Despite substantial success in the anesthetic and surgical management of cardiac surgery, patients frequently show postoperative complications and organ dysfunctions. This is highly relevant for mid- to long-term outcomes. OBJECTIVES To evaluate cardioprotective strategies that may offer effective protection in vulnerable cardiac surgery patients. METHODS To demonstrate recent cardioprotective approaches for cardiac surgery patients, aiming to modulate the body's own protective mechanisms in cardiac surgery patients. RESULTS Both cardioplegia and hypothermia belong to the well-established protective strategies during myocardial ischemia. Volatile anesthetics have been repeatedly shown to improve the left ventricular function and reduce the extent of myocardial injury compared to a control group with intravenous anesthesia. Furthermore, patients receiving volatile anesthetics showed a significantly shortened stay in the ICU and in hospital after cardiac surgery. In contrast, numerous other protective strategies failed translation into the clinical practice. Despite the published reduction of troponin release after remote ischemic preconditioning, two recent large-scale randomized multicenter trials were unable to demonstrate a clinical benefit. CONCLUSIONS Beside the use of cardioplegia and hypothermia, the use of volatile anesthetics is well-established during cardiac surgery because of its conditioning and protective properties. Regardless of the promising results derived from experimental studies and small clinical trials, the majority of other approaches failed to translate their findings into the clinic. Therefore, systematic experimental studies are needed to identify potential confounding factors that may affect the protective effects.
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Smit JWA, Romijn JA. Acute Insulin Resistance in Myocardial Ischemia: Causes and Consequences. Semin Cardiothorac Vasc Anesth 2016; 10:215-9. [PMID: 16959753 DOI: 10.1177/1089253206291153] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Diabetes mellitus is associated with increased risk for cardiovascular mortality because of multiple pathophysiologic mechanisms. Acute stress-induced hyper-glycemia during acute myocardial infarction has gained much attention, as blood glucose levels seem to be an independent risk factor for acute myocardial infarction–related death. Clinical studies that identify stress-induced hyperglycemia as a risk factor are reviewed and its causes are discussed. They can be summarized as the consequence of acute insulin resistance, which in its turn is caused by stress hormones and by proinflammatory cytokines. Hyperglycemia causes the release of proinflammatory cytokines, the induction of reactive radicals, alterations in cardiovascular substrate metabolism, and propagation of coagulation and apoptosis. These all have harmful effects during and after acute myocardial infarction. Recommendations are for strict glycemic control in hyperglycemic patients with acute myocar-dial infarction, although the target glucose level is still a subject of debate.
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Affiliation(s)
- Johannes W A Smit
- Department of Endocrinology and Metabolic Diseasis, Leiden University Medical Center, RC Leiden, The Netherlands.
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Quinn DW, Pagano D, Bonser RS. Glucose and Insulin Influences on Heart and Brain in Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2016; 9:173-8. [PMID: 15920645 DOI: 10.1177/108925320500900213] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The elective global ischemia of on-pump coronary artery bypass surgery contributes to the incidence of postoperative mortality, complications, and use of resources. In addition to cardiopulmonary bypass and techniques for myocardial protection such as aortic cross clamp, ventricular fibrillation, and cardioplegia, the administration of systemic glucose-insulinpotassium (GIK) in the perioperative period may act as both a metabolic modulator and potential inodilator. GIK may therefore serve to protect the myocardium and promote adequate cardiac and hemodynamic performance that would improve patient recovery. Cell, tissue, and animal experiments have determined a number of mechanisms of action by which this may be achieved, with increasing focus on insulin as the key component. The original concepts centered on GIK during or after ischemia switching metabolism away from that based on nonesterified fatty acids toward a more favorable glucose-based metabolism and thus improving the efficiency of adenosine triphosphate production and glycogen preservation. Insulin's ability to reduce intracellular fatty acid metabolism may also reduce cellular membrane damage. More recently other mechanisms have also been suggested, including osmotic, oxygen free radical scavenging, and antiapoptotic and anti-inflammatory effects. However, trials that have examined the role of GIK in cardiac surgery have been small, open label, and involved a wide variety of regimens. They have demonstrated improved glycogen preservation, reduced infarct size, reduced incidences of dysrhythmias, need for inotropic agents, and low cardiac output state, and overall reduced lengths of stay. The perceived need to achieve strict blood glucose control to reduce neurologic injury and improve overall mortality have conflicted with its practical difficulties, particularly during cold cardiopulmonary bypass, and the exact role of supplemental glucose administration and resulting hyperglycemia require re-examination.
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Affiliation(s)
- David W Quinn
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Edgbaston, United Kingdom
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Slettom G, Jonassen AK, Dahle GO, Seifert R, Larsen TH, Berge RK, Nordrehaug JE. Insulin Postconditioning Reduces Infarct Size in the Porcine Heart in a Dose-Dependent Manner. J Cardiovasc Pharmacol Ther 2016; 22:179-188. [PMID: 27390144 DOI: 10.1177/1074248416657611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
AIM Insulin and glucose may have opposite effects when used to reduce ischemia-reperfusion injury. When insulin is administered alone, feeding state determines tolerance and further induces metabolic and hormonal changes. Higher insulin doses are needed for similar activation of cardioprotective Akt signaling in the fed compared to the fasted pig heart. Thus, the aim of the study was to investigate the effects of 2 prespecified insulin doses on infarct size, apoptosis, metabolism, and cardiac function in a clinically relevant, randomized large animal model using conventional percutaneous catheter intervention techniques and including different fasting states. METHODS AND RESULTS Twenty-seven female pigs were subjected to 40-minute ischemia and 120-minute reperfusion. Pharmacological postconditioning with intracoronary infusions administered over 3 × 30 seconds was performed at immediate reperfusion. Animals were randomly assigned to 3 groups-preexperimental fasting and intracoronary saline ( controls), preexperimental fasting and 0.1U of insulin ( fasted Ins0.1U), and preexperimental feeding and 1.0U of insulin ( fed Ins1.0U). A significant reduction in infarct size was demonstrated in the fed Ins1.0U group ( P = .047) but not in the fasted Ins0.1U group ( P = .531) compared to controls (infarct size normalized to area at risk ± standard deviation: controls 70.2% ± 12.9%, fasted Ins0.1U 65.0% ± 9.4%, and fed Ins1.0U 54.4% ± 7.3%). Infarct limitation was associated with more uncleaved caspase-3 in the area of risk and the infarcted area, lower circulating free fatty acids, and less increase in heart rate during reperfusion. Fed animals had higher levels of glucose, carnitine, potassium, and normetanephrine and higher heart rate at baseline compared to controls. CONCLUSION Insulin postconditioning reduced infarct size in the in vivo pig heart, but the beneficial effects were restricted to the highest dose, which is limited by side effects and can only be given to nonfasted animals. The finding challenges successful general use of insulin in the treatment of reperfusion injury in clinical acute myocardial infarction.
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Affiliation(s)
- Grete Slettom
- 1 Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,2 Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Anne K Jonassen
- 3 Department of Biomedicine, University of Bergen, Bergen, Norway.,4 Faculty of Health Care and Nursing, NTNU, Bergen, Norway
| | - Geir O Dahle
- 2 Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Reinhard Seifert
- 1 Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Terje H Larsen
- 1 Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,3 Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Rolf K Berge
- 2 Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Jan E Nordrehaug
- 2 Department of Clinical Science, University of Bergen, Bergen, Norway
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Ali-Hassan-Sayegh S, Mirhosseini SJ, Zeriouh M, Dehghan AM, Shahidzadeh A, Karimi-Bondarabadi AA, Sabashnikov A, Popov AF. Safety and efficacy of glucose–insulin–potassium treatment in coronary artery bypass graft surgery and percutaneous coronary intervention. Interact Cardiovasc Thorac Surg 2015; 21:667-76. [DOI: 10.1093/icvts/ivv222] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 07/09/2015] [Indexed: 11/13/2022] Open
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Czibik G, Steeples V, Yavari A, Ashrafian H. Citric Acid Cycle Intermediates in Cardioprotection. ACTA ACUST UNITED AC 2014; 7:711-9. [DOI: 10.1161/circgenetics.114.000220] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Over the last decade, there has been a concerted clinical effort to deliver on the laboratory promise that a variety of maneuvers can profoundly increase cardiac tolerance to ischemia and/or reduce additional damage consequent upon reperfusion. Here we will review the proximity of the metabolic approach to clinical practice. Specifically, we will focus on how the citric acid cycle is involved in cardioprotection. Inspired by cross-fertilization between fundamental cancer biology and cardiovascular medicine, a set of metabolic observations have identified novel metabolic pathways, easily manipulable in man, which can harness metabolism to robustly combat ischemia-reperfusion injury.
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Affiliation(s)
- Gabor Czibik
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Violetta Steeples
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Arash Yavari
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Houman Ashrafian
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
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9
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Salminen PR, Dahle GO, Moen CA, Jonassen AK, Haaverstad R, Matre K, Grong K. Intracoronary insulin administered at reperfusion in a porcine model of acute coronary syndrome. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:230-40. [PMID: 25147200 DOI: 10.1177/2048872614547689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 07/28/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Experimental studies have demonstrated that insulin elicits cardioprotection in coronary occlusion-reperfusion models. We studied the effects of intracoronary insulin on regional cardiac function in a porcine model with reperfusion after a critical coronary artery stenosis. METHODS In 20 anaesthetized pigs with an extracorporeal shunt from the brachiocephalic to the left anterior descending coronary artery, a fixed stenosis was applied, obtaining 50% reduction of shunt flow for 60 min. Intracoronary insulin 1 1U [DOSAGE ERROR CORRECTED] or 0.9% saline was infused for 15 min, starting 5 min prior to initiation of 180 min of reperfusion. Microsphere injections confirmed ischaemia and reperfusion. Epicardial echocardiographic multilayer radial tissue Doppler strain and strain rate and one-layer speckle-tracking strain evaluated myocardial function. Apoptosis was evaluated by cleaved caspase-3 activity. Area at risk and infarct size were determined with Evans Blue and triphenyltetrazolium chloride staining. RESULTS In both groups, the area at risk constituted approximately 26% of the left ventricular mass. Minor areas of infarction were predominantly seen subendocardially, where tissue blood flow rate was severely reduced during stenosis. After 180 min of reperfusion, recovery of speckle-tracking circumferential strain averaged 57.5 ± 11.4% of baseline values in insulin treated animals compared to 22.3 ± 8.7% in controls (p = 0.025). Multilayer radial strain and strain rate did not differ between groups. Cleaved caspase-3 activity was most prominent in the subepicardial layer in the saline-treated group. CONCLUSIONS Intracoronary insulin at the onset of reperfusion alleviated regional myocardial dysfunction in acute ischaemia-reperfusion and was associated with a reduction of apoptosis.
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Affiliation(s)
- Pirjo-Riitta Salminen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Norway
| | - Geir Olav Dahle
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Norway
| | - Christian Arvei Moen
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Norway
| | - Anne Kristine Jonassen
- Department of Biomedicine, Faculty of Medicine and Dentistry, University of Bergen, Norway
| | - Rune Haaverstad
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Norway
| | - Knut Matre
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Norway
| | - Ketil Grong
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Norway
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Sivaraman V, Yellon DM. Pharmacologic therapy that simulates conditioning for cardiac ischemic/reperfusion injury. J Cardiovasc Pharmacol Ther 2013; 19:83-96. [PMID: 24038018 DOI: 10.1177/1074248413499973] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Cardiovascular disease remains a leading cause of deaths due to noncommunicable diseases, of which ischemic heart disease forms a large percentage. The main therapeutic strategy to treat ischemic heart disease is reperfusion that could either be medical or surgical. However, reperfusion following ischemia is known to increase the infarct size further. Newer strategies such as ischemic preconditioning (IPC), ischemic postconditioning, and remote IPC have been shown to condition the myocardium to ischemia-reperfusion injury and thus reduce the final infarct size. Research over the past 3 decades has deepened our understanding of cellular and subcellular pathways that mediate ischemia-reperfusion injury. This in turn has resulted in the development of several pharmacological agents that act as conditioning agents, which reduce the final myocardial infarct size following ischemia-reperfusion. This review discusses many of these agents, their mechanisms of action, and the animal and clinical evidence behind them.
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Affiliation(s)
- Vivek Sivaraman
- 1The Hatter Cardiovascular Institute, University College London, London, United Kingdom
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11
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Sharma V, Bell RM, Yellon DM. Targeting reperfusion injury in acute myocardial infarction: a review of reperfusion injury pharmacotherapy. Expert Opin Pharmacother 2012; 13:1153-75. [PMID: 22594845 DOI: 10.1517/14656566.2012.685163] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Acute myocardial infarction (AMI) (secondary to lethal ischemia-reperfusion [IR]) contributes to much of the mortality and morbidity from ischemic heart disease. Currently, the treatment for AMI is early reperfusion; however, this itself contributes to the final myocardial infarct size, in the form of what has been termed 'lethal reperfusion injury'. Over the last few decades, the discovery of the phenomena of ischemic preconditioning and postconditioning, as well as remote preconditioning and remote postconditioning, along with significant advances in our understanding of the cardioprotective pathways underlying these phenomena, have provided the possibility of successful mechanical and pharmacological interventions against reperfusion injury. AREAS COVERED This review summarizes the evidence from clinical trials evaluating pharmacological agents as adjuncts to standard reperfusion therapy for ST-elevation AMI. EXPERT OPINION Reperfusion injury pharmacotherapy has moved from bench to bedside, with clinical evaluation and ongoing clinical trials providing us with valuable insights into the shortcomings of current research in establishing successful treatments for reducing reperfusion injury. There is a need to address some key issues that may be leading to lack of translation of cardioprotection seen in basic models to the clinical setting. These issues are discussed in the Expert opinion section.
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Affiliation(s)
- Vikram Sharma
- The Hatter Cardiovascular Institute, 67 Chenies Mews, London WC1E 6HX, UK
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Klein LJ, Visser FC. The effect of insulin on the heart : Part 1: Effects on metabolism and function. Neth Heart J 2011; 18:197-201. [PMID: 20428418 DOI: 10.1007/bf03091761] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Positive inotropic effects of insulin were described early after the isolation of insulin from the pancreas but data on the effect of insulin on the heart are conflicting. Systemic insulin administration results in a reduction in circulating free fatty acids and an improvement in myocardial glucose uptake, which causes an efficiency improvement in the myocardial cell. There is strong evidence that insulin administration results in functional improvement in dysfunctional myocardium. (Neth Heart J 2010;18:197-201.).
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Affiliation(s)
- L J Klein
- Department of Cardiology, VU Medical Centre, Amsterdam, the Netherlands
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Klein LJ, Visser FC. The effect of insulin on the heart: Part 2: Effects on function during and post myocardial ischaemia. Neth Heart J 2011; 18:255-9. [PMID: 20505799 DOI: 10.1007/bf03091772] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Insulin infusion has been advocated in the treatment of myocardial ischaemia and myocardial infarction. There is evidence from experimental animal studies for a protective effect of high-dose insulin administration in myocardial ischaemia and myocardial infarction. In some relatively small study populations a reduction in mortality was reported in those patients who received glucose-insulin-potassium (GIK) during myocardial infarction, which was confirmed in two meta-analyses. However, it has not been possible to reproduce these positive results in large randomised clinical trials. (Neth Heart J 2010;18:255-9.).
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Affiliation(s)
- L J Klein
- Department of Cardiology, VU Medical Centre, Amsterdam, the Netherlands
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Klein LJ, van Campen CMC, Sieswerda GT, Kamp O, Visser FC. Effects of high-dose insulin infusion on left ventricular function in normal subjects. Neth Heart J 2011; 18:183-9. [PMID: 20428416 DOI: 10.1007/bf03091759] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background. Only a few studies have reported on the effect of high-dose insulin (HDI) infusion on cardiac function in healthy volunteers. Methods. We studied ten healthy volunteers with low-dose dobutamine (LDD, 10 mug/kg/min) echo-cardio-graphy and HDI echocardiography (insulin administration for one hour) by volume and Doppler analysis. Results. During LDD, cardiac output increased from 5.7+/-1.3 l/min to 9.0+/-2.1 l/min (p<0.001) and during HDI from 5.5+/-1.2 l/min to 6.2+/-1.1 l/min (p=0.048). Increase was not only due to increase in frequency, which was only present in the LDD study, but also due to increase in stroke volume (from 82+/-15 ml to 110+/-23 ml, p<0.001 during LDD and from 82+/-16 ml to 93+/-24 ml, p=0.014 during HDI). The increase in stroke volume was the result of a decrease in end-systolic volume with an unchanged end-diastolic volume. Conclusion. High-dose insulin infusion results in increased cardiac output by improving systolic myocardial function. (Neth Heart J 2010;18:183-9.).
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Affiliation(s)
- L J Klein
- Department of Cardiology, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, the Netherlands
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Effects of GIK (glucose-insulin-potassium) on stress-induced myocardial ischaemia. Clin Sci (Lond) 2010; 119:37-44. [PMID: 20001969 DOI: 10.1042/cs20090438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite the evidence in experimental animal models that insulin, or GIK (glucose-insulin-potassium), improves left ventricular function and perfusion during both acute and chronic ischaemia, clinical studies have generated conflicting results. We tested the hypothesis that pretreatment with GIK attenuates the vascular and functional effects of stress-induced myocardial ischaemia in humans. Twenty-two patients with evidence of inducible myocardial ischaemia were enrolled; 11 patients with normal ventricular function underwent two dipyridamole echocardiography tests, and 11 with regional contractility defects from previous myocardial infarction were submitted to two ECG exercise tests combined with 201Tl myocardial perfusion scintigraphy; the tests were preceded by 60 min of either normal saline or an isoglycaemic GIK infusion. On a stress echocardiogram, a 30% reduction in the severity of ischaemia was observed. On ECG ergometry, GIK infusion slightly increased the time to ischaemia (+0.6 min, P=0.07); however, the higher workload (+8%, P=0.07) was achieved at a similar rate-pressure plateau. On scintigraphy, an increase in ischaemic segments (+48%, P<0.001) was imaged mainly at the expense of viable (but non-ischaemic) and non-viable segments, which were reduced by 60%. GIK affected stress-induced left ventricular underperfusion only marginally (GIK: 39.7+/-2.5 compared with saline: 35.4+/-2.2 units, P<0.05), but significantly improved its acute reversibility (-42+/-4 compared with -25+/-4%, P<0.001). We conclude that GIK pretreatment attenuates the effect of ischaemia on myocardial contractility, slightly improves exercise tolerance and causes a more rapid and diffuse recovery of post-ischaemic reperfusion.
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Abstract
High-dose intravenous infusion of 5% glucose promotes rebound hypoglycaemia and hypovolaemia in healthy volunteers. To study whether such effects occur in response to glucose/insulin, 12 healthy firemen (mean age, 39 years) received three infusions over 1-2 h that contained 20 ml of 2.5% glucose/kg of body weight, 5 ml of 10% glucose/kg of body weight with 0.05 unit of rapid-acting insulin/kg of body weight, and 4 ml of 50% glucose/kg of body weight with 1 unit of insulin/kg of body weight. The plasma glucose concentration and plasma dilution were compared at 5-10 min intervals over 4 h. Regardless of the amount of administered fluid and whether insulin was given, the plasma glucose concentration decreased to hypoglycaemic levels within 30 min of the infusion ending. The plasma dilution closely mirrored plasma glucose and became negative by approx. 5%, which indicates a reduction in the plasma volume. These alterations were only partially restored during the follow-up period. A linear relationship between plasma glucose and plasma dilution was most apparent when the infused glucose had been dissolved in only a small amount of fluid. For the strongest glucose/insulin solution, this linear relationship had a correlation coefficient of 0.77 (n=386, P<0.0001). The findings of the present study indicate that a redistribution of water due to the osmotic strength of the glucose is the chief mechanism accounting for the hypovolaemia. It is concluded that infusions of 2.5%, 10% and 50% glucose, with and without insulin, in well-trained men were consistently followed by long-standing hypoglycaemia and also by hypovolaemia, which averaged 5%. These results emphasize the relationship between metabolism and fluid balance.
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Zuurbier CJ, Van Wezel HB. Glucose-insulin therapy, plasma substrate levels and cardiac recovery after cardiac ischemic events. Cardiovasc Drugs Ther 2008; 22:125-31. [PMID: 18266096 PMCID: PMC2329728 DOI: 10.1007/s10557-008-6087-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Accepted: 01/17/2008] [Indexed: 01/04/2023]
Abstract
Introduction The potential usefulness of glucose-insulin therapy relies to a large extent on the premise that it prevents hyperglycemia and hyperlipidemia following cardiac ischemic events. Methods In this review we evaluate the literature concerning plasma glucose and free fatty acids levels during and following cardiac ischemic events. Results The data indicate that hyperlipidemia and hyperglycemia most likely occur during acute coronary ischemic syndromes in the conscious state (e.g. acute myocardial infarction) and less so during reperfusion following CABG reperfusion. This is in accordance with observations that glucose-insulin therapy during early reperfusion post CABG may actually cause hypolipidemia, because substantial hyperlipidemia does not appear to occur during that stage of cardiac surgery. Discussion Considering recent data indicating that hypolipidemia may be detrimental for cardiac function, we propose that free fatty acid levels during reperfusion post CABG with the adjunct glucose-insulin therapy need to be closely monitored. Conclusion From a clinical point of view, a strategy directed at monitoring and thereafter maintaining plasma substrate levels in the normal range for both glucose (4–6 mM) and FFA (0.2–0.6 mM) as well as stimulation of glucose oxidation, promises to be the most optimal metabolic reperfusion treatment following cardiac ischemic episodes. Future (preclinical and subsequently clinical) investigations are required to investigate whether the combination of glucose-insulin therapy with concomitant lipid administration may be beneficial in the setting of reperfusion post CABG.
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Affiliation(s)
- C J Zuurbier
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Zhou L, Huang H, McElfresh TA, Prosdocimo DA, Stanley WC. Impact of anaerobic glycolysis and oxidative substrate selection on contractile function and mechanical efficiency during moderate severity ischemia. Am J Physiol Heart Circ Physiol 2008; 295:H939-H945. [PMID: 18660443 DOI: 10.1152/ajpheart.00561.2008] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The role of anaerobic glycolysis and oxidative substrate selection on contractile function and mechanical efficiency during moderate severity myocardial ischemia is unclear. We hypothesize that 1) preventing anaerobic glycolysis worsens contractile function and mechanical efficiency and 2) increasing glycolysis and glucose oxidation while inhibiting free fatty acid oxidation improves contractile function during ischemia. Experiments were performed in anesthetized pigs, with regional ischemia induced by a 60% decrease in left anterior descending coronary artery blood flow for 40 min. Three groups were studied: 1) no treatment, 2) inhibition of glycolysis with iodoacetate (IAA), or 3) hyperinsulinemia and hyperglycemia (HI + HG). Glucose and free fatty acid oxidation were measured using radioisotopes and anaerobic glycolysis from net lactate efflux and myocardial lactate content. Regional contractile power was assessed from left ventricular pressure and segment length in the anterior wall. We found that preventing anaerobic glycolysis with IAA during ischemia in the absence of alterations in free fatty acid and glucose oxidation did not adversely affect contractile function or mechanical efficiency during myocardial ischemia, suggesting that anaerobic glycolysis is not essential for maintaining residual contractile function. Increasing glycolysis and glucose oxidation with HI + HG inhibited free fatty acid oxidation and improved contractile function and mechanical efficiency. In conclusion, these results show a dissociation between myocardial function and anaerobic glycolysis during moderate severity ischemia in vivo, suggesting that metabolic therapies should not be aimed at inhibiting anaerobic glycolysis per se, but rather activating insulin signaling and/or enhancing carbohydrate oxidation and/or decreasing fatty acid oxidation.
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Affiliation(s)
- Lufang Zhou
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
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Lu L, Reiter MJ, Xu Y, Chicco A, Greyson CR, Schwartz GG. Thiazolidinedione drugs block cardiac KATP channels and may increase propensity for ischaemic ventricular fibrillation in pigs. Diabetologia 2008; 51:675-85. [PMID: 18251006 PMCID: PMC3633423 DOI: 10.1007/s00125-008-0924-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Accepted: 12/04/2007] [Indexed: 01/25/2023]
Abstract
AIMS/HYPOTHESIS Opening of ATP-sensitive potassium (K(ATP)) channels during myocardial ischaemia shortens action potential duration and is believed to be an adaptive, energy-sparing response. Thiazolidinedione drugs block K(ATP) channels in non-cardiac cells in vitro. This study determined whether thiazolidinedione drugs block cardiac K(ATP) channels in vivo. METHODS Experiments in 68 anaesthetised pigs determined: (1) effects of inert vehicle, troglitazone (10 mg/kg i.v.) or rosiglitazone (0.1 or 1.0 mg/kg i.v.) on epicardial monophasic action potential (MAP) during 90 min low-flow ischaemia; (2) effects of troglitazone, rosiglitazone or pioglitazone (1 mg/kg i.v.) on response of MAP to intracoronary infusion of a K(ATP) channel opener, levcromakalim; and (3) effects of inert vehicle, rosiglitazone (1 mg/kg i.v.) or the sarcolemmal K(ATP) blocker HMR-1098 on time to onset of ventricular fibrillation following complete coronary occlusion. RESULTS With vehicle, epicardial MAP shortened by 44+/-9 ms during ischaemia. This effect was attenuated to 12+/-8 ms with troglitazone and 6+/-6 ms with rosiglitazone (p<0.01 for both vs vehicle), suggesting K(ATP) blockade. Intracoronary levcromakalim shortened MAP by 38+/-10 ms, an effect attenuated to 12+/-8, 13+/-4 and 9+/-5 ms during co-treatment with troglitazone, rosiglitazone or pioglitazone (p<0.05 for each), confirming K(ATP) blockade. During coronary occlusion, median time to ventricular fibrillation was 29 min in pigs treated with vehicle and 6 min in pigs treated with rosiglitazone or HMR-1098 (p<0.05 for both vs vehicle), indicating that K(ATP) blockade promotes ischaemic ventricular fibrillation in this model. CONCLUSIONS/INTERPRETATION Thiazolidinedione drugs block cardiac K(ATP) channels at clinically relevant doses and promote onset of ventricular fibrillation during severe ischaemia.
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Affiliation(s)
- L Lu
- VA Medical Center and University of Colorado Health Sciences Center, Denver, CO 80220, USA
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Kalay N, Ozdogru I, Gul A, Yucel Y, Cetinkaya Y, Inanc MT, Dogan A, Kaya MG, Eryol NK. Effects of intermittent and long-term glucose-insulin-potassium infusion in patients with systolic heart failure. Exp Clin Cardiol 2008; 13:85-8. [PMID: 19343122 PMCID: PMC2586402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2008] [Accepted: 02/13/2008] [Indexed: 05/27/2023]
Abstract
BACKGROUND Although single dose and short-term glucose-insulin-potassium (GIK) infusions are known to have positive cardiac effects, the effects of repeated and long-term GIK infusion on left ventricular (LV) systolic function and brain natriuretic peptide (BNP) levels are unknown. OBJECTIVE To investigate the effects of repeated and long-term GIK infusion on LV systolic function and BNP levels. METHODS Thirty-three patients diagnosed with ischemic cardiomyopathy were included in the study. Patients were divided into two groups: the GIK group (n=19) and the control group (n=14). GIK solutions (1000 mL 20% dextrose, 60 U insulin and 50 mmol/L KCl) were administered at 1 mL/kg/h for 24 h on the first, third and fifth days. The patients were examined by echocardiography at 24 h, one week and one month after the start of treatment. BNP levels were measured before and after GIK infusion. RESULTS In the GIK group, baseline ejection fraction (EF) was 29.2+/-10.3%. After one week, EF elevated to 40.8+/-10.8% (P=0.001). The EF after one month (37.1+/-10.9%) was less than the EF in the first week, but it was significantly higher than baseline in the GIK group (P=0.01). However, no significant changes in EF were observed after one week and one month in the control group (P=0.1 and P=0.2, respectively). BNP levels after GIK infusion was significantly lower than baseline level in the GIK group (P=0.01). CONCLUSION Intermittent and long-term GIK infusion has beneficial effects on LV systolic function in a short and intermediate amount of time. Decrease in BNP levels may indicate effective GIK treatment. Intermittent and long-term GIK infusion could be a promising treatment option in patients with systolic heart failure.
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Affiliation(s)
- Nihat Kalay
- Department of Cardiology, Sorgun State Hospital, Yozgat, Turkey
| | - Ibrahim Ozdogru
- Department of Cardiology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Ali Gul
- Department of Cardiology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Yilmaz Yucel
- Department of Cardiology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Yakup Cetinkaya
- Department of Cardiology, Adiyaman Public Hospital, Adiyaman, Turkey
| | - Mehmet Tugrul Inanc
- Department of Cardiology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Ali Dogan
- Department of Cardiology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Mehmet Gungor Kaya
- Department of Cardiology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Namýk Kemal Eryol
- Department of Cardiology, Erciyes University Medicine Faculty, Kayseri, Turkey
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Shimizu M, Konstantinov IE, Kharbanda RK, Cheung MH, Redington AN. Effects of intermittent lower limb ischaemia on coronary blood flow and coronary resistance in pigs. Acta Physiol (Oxf) 2007; 190:103-9. [PMID: 17394577 DOI: 10.1111/j.1748-1716.2007.01667.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Intermittent limb ischaemia prior to cardiac ischaemia is a cardioprotective stimulus. This study was to investigate whether this peripheral stimulus had any effects on basal coronary blood flow and resistance, and to explore its potential mechanisms by studying the effect of femoral nerve transection and Katp blockade by glibenclamide. METHODS Remote ischaemic preconditioning (rIPC) was induced by four 5-min cycles of lower limb ischaemia. Coronary resistance was measured using standard formulae and coronary blood flow in the left anterior descending artery (LAD) by a flow probe. In experiment 1, coronary ischaemia was induced by inflation of a cuff placed around the mid-LAD, and inflated until cessation of flow. Left ventricular (LV) function was assessed using dp/dt and Tau at 1 and 30 min of ischaemia. Experiment 1: 20 pigs were randomized to control (n = 6), rIPC (n = 7) or femoral nerve transection + rIPC (n = 7) groups. The femoral nerve was transected before the rIPC protocol. All data were collected at fixed heart rates of 120 bpm. Coronary resistance was decreased and flow was increased significantly by the rIPC stimulus (P = 0.003, P = 0.016, paired t-test), and these changes were preserved after femoral nerve transection. Experiment 2: 19 pigs were randomized to control (n = 5), rIPC (n = 8) or glibenclamide-treated rIPC (n = 6) groups. Data were collected at baseline, and during incremental pacing between 120 and 180 bpm. RESULTS Experiment 1: Coronary resistance was decreased and flow was increased significantly by rIPC stimulus (P = 0.003, P = 0.016, paired t-test), and these changes were preserved after femoral nerve transaction. rIPC was associated with superior LV function (dp/dt(max)) at 30 min, compared with controls and the rIPC + femoral nerve transaction group. Experiment 2: Coronary resistance was significantly lower, and LAD flow was significantly higher in rIPC group (P < 0.0001, P = 0.0008, two-way anova). These effects were reversed in the glibenclamide group. CONCLUSION The rIPC stimulus leads to reduced coronary resistance and increased flow. This effect, while modified by glibenclamide appears to be a generic effect of remote ischaemia rather than a direct preconditioning effect.
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Affiliation(s)
- M Shimizu
- Division of Cardiology, Hospital for Sick Children, Toronto, ON, Canada
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Shim YH, Kweon TD, Lee JH, Nam SB, Kwak YL. Intravenous glucose-insulin-potassium during off-pump coronary artery bypass surgery does not reduce myocardial injury. Acta Anaesthesiol Scand 2006; 50:954-61. [PMID: 16923090 DOI: 10.1111/j.1399-6576.2006.01115.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND This randomized, double-blind, placebo-controlled study was designed to determine whether an intra-operative, intravenous infusion of glucose-insulin-potassium (GIK) could be helpful in the prevention of myocardial ischemia and in the maintenance of intra-operative cardiac performance in patients undergoing off-pump coronary artery bypass (OP-CAB) surgery. METHODS Eighty two adults undergoing elective OP-CAB surgery were randomly divided into two groups that received intravenously either 5% dextrose in water or GIK (50% dextrose in 500 ml of water; regular insulin, 125 IU; potassium, 80 mmol) at 0.75 ml/kg/h immediately before the induction of anesthesia to the end of surgery. To evaluate myocardial damage, creatine kinase MB and troponin T were measured before surgery, immediately after arrival in the intensive care unit and on the first post-operative day. To assess cardiac performance, hemodynamic data were obtained before and after the induction of anesthesia, before and after the bypass graft and after sternal closure. Blood glucose was measured at the same time. RESULTS There was no significant difference in cardiac enzymes, hemodynamic parameters and blood glucose between the two groups. The use of vasoactive, inotropic and/or anti-arrhythmic agents, insulin and supplemental glucose was not significantly different between the groups. CONCLUSION The results suggest that the intravenous administration of GIK during OP-CAB surgery neither reduces myocardial damage nor improves intra-operative cardiac performance in patients without contractile dysfunction.
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Affiliation(s)
- Y H Shim
- Department of Anesthesiology & Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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Bergstra A, Svilaas T, van den Heuvel AFM, van der Horst ICC, Zijlstra F. Glucose-insulin-potassium infusion in acute myocardial infarction: a hemodynamic study. Am Heart J 2006; 151:345-51. [PMID: 16442897 DOI: 10.1016/j.ahj.2005.04.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2004] [Accepted: 04/28/2005] [Indexed: 01/04/2023]
Abstract
BACKGROUND In this study, we investigated whether adjunction of glucose-insulin-potassium (GIK) infusion to primary percutaneous coronary intervention (PCI) affects hemodynamics in patients with an acute myocardial infarction. METHODS Hemodynamic measurements were performed in a subset of patients (n = 81) in the GIPS 2, starting immediately after PCI and continued for 12 hours. RESULTS Cardiac index values were stable in both groups. During the first measurements, diastolic pulmonary artery pressure and the pulmonary capillary wedge pressure (PCWP) were significantly higher in the non-GIK group (diastolic pulmonary artery pressure 15 +/- 5 vs 18 +/- 7 mm Hg, P = .028 and PCWP 14 +/- 6 vs 18 +/- 7 mm Hg, P = .030). There was a decrease in PCWP from 18 +/- 7 to 15 +/- 6 mm Hg in the non-GIK group during the first 6 hours, whereas the pressures remained at 14 +/- 6 mm Hg in the GIK group. This difference in pattern of change did not reach statistical significance in the analysis of the interaction of PCWP by GIK group (P = .065). CONCLUSIONS Glucose-insulin-potassium infusion as adjunctive therapy to PCI in patients with acute myocardial infarction, without overt signs of heart failure, did not negatively affect hemodynamics.
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Affiliation(s)
- Arend Bergstra
- Department of Cardiology, Thorax Center, University Medical Center Groningen, Groningen, The Netherlands
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van der Horst ICC, Ottervanger JP, van 't Hof AWJ, Reiffers S, Miedema K, Hoorntje JCA, Dambrink JHE, Gosselink ATM, Nijsten MWN, Suryapranata H, de Boer MJ, Zijlstra F. The impact of glucose-insulin-potassium infusion in acute myocardial infarction on infarct size and left ventricular ejection fraction [ISRCTN56720616]. BMC Med 2005; 3:9. [PMID: 15932638 PMCID: PMC1177952 DOI: 10.1186/1741-7015-3-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2004] [Accepted: 06/02/2005] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Favorable clinical outcomes have been observed with glucose-insulin-potassium infusion (GIK) in acute myocardial infarction (MI). The mechanisms of this beneficial effect have not been delineated clearly. GIK has metabolic, anti-inflammatory and profibrinolytic effects and it may preserve the ischemic myocardium. We sought to assess the effect of GIK infusion on infarct size and left ventricular function, as part of a randomized controlled trial. METHODS Patients (n = 940) treated for acute MI by primary percutaneous coronary intervention (PCI) were randomized to GIK infusion or no infusion. Endpoints were the creatinine kinase MB-fraction (CK-MB) and left ventricular ejection fraction (LVEF). CK-MB levels were determined 0, 2, 4, 6, 24, 48, 72 and 96 hours after admission and the LVEF was measured before discharge. RESULTS There were no differences between the two groups in the time course or magnitude of CK-MB release: the peak CK-MB level was 249 +/- 228 U/L in the GIK group and 240 +/- 200 U/L in the control group (NS). The mean LVEF was 43.7 +/- 11.0 % in the GIK group and 42.4 +/- 11.7% in the control group (P = 0.12). A LVEF < or = 30% was observed in 18% in the controls and in 12% of the GIK group (P = 0.01). CONCLUSION Treatment with GIK has no effect on myocardial function as determined by LVEF and by the pattern or magnitude of enzyme release. However, left ventricular function was preserved in GIK treated patients.
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Affiliation(s)
- Iwan CC van der Horst
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, Hanzeplein 1, 9700 RB Groningen, the Netherlands
- Department of Cardiology, Isala Klinieken, locatie Weezenlanden, Groot Wezenland 20, 8011 JW Zwolle, the Netherlands
| | - Jan Paul Ottervanger
- Department of Cardiology, Isala Klinieken, locatie Weezenlanden, Groot Wezenland 20, 8011 JW Zwolle, the Netherlands
| | - Arnoud WJ van 't Hof
- Department of Cardiology, Isala Klinieken, locatie Weezenlanden, Groot Wezenland 20, 8011 JW Zwolle, the Netherlands
| | - Stoffer Reiffers
- Department of Nuclear Medicine, Isala Klinieken, locatie Weezenlanden, Groot Wezenland 20, 8011 JW Zwolle, the Netherlands
| | - Kor Miedema
- Department of Clinical Chemistry, Isala Klinieken, locatie Weezenlanden, Groot Wezenland 20, 8011 JW Zwolle, the Netherlands
| | - Jan CA Hoorntje
- Department of Cardiology, Isala Klinieken, locatie Weezenlanden, Groot Wezenland 20, 8011 JW Zwolle, the Netherlands
| | - Jan-Henk E Dambrink
- Department of Cardiology, Isala Klinieken, locatie Weezenlanden, Groot Wezenland 20, 8011 JW Zwolle, the Netherlands
| | - AT Marcel Gosselink
- Department of Cardiology, Isala Klinieken, locatie Weezenlanden, Groot Wezenland 20, 8011 JW Zwolle, the Netherlands
| | - Maarten WN Nijsten
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, the Netherlands
| | - Harry Suryapranata
- Department of Cardiology, Isala Klinieken, locatie Weezenlanden, Groot Wezenland 20, 8011 JW Zwolle, the Netherlands
| | - Menko-Jan de Boer
- Department of Cardiology, Isala Klinieken, locatie Weezenlanden, Groot Wezenland 20, 8011 JW Zwolle, the Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, Hanzeplein 1, 9700 RB Groningen, the Netherlands
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Wong VW, Ross DL, Park K, Boyages SC, Cheung NW. Hyperglycemia: still an important predictor of adverse outcomes following AMI in the reperfusion era. Diabetes Res Clin Pract 2004; 64:85-91. [PMID: 15063600 DOI: 10.1016/j.diabres.2003.10.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2003] [Indexed: 01/08/2023]
Abstract
Hyperglycemia in patients admitted to hospital with myocardial infarction has been associated with adverse outcomes. However, with the improvements in survival seen in the reperfusion era, the glycometabolic state of patients presenting with acute myocardial infarction (AMI) is often given a low priority. The aim of this study was to determine if hyperglycemia remains a significant predictor of cardiac mortality and morbidity in the reperfusion era. We conducted a retrospective review of 158 patients presenting with AMI to our institution, where reperfusion therapy is routinely administered. The glucose level on admission and other risk factors were correlated against adverse cardiac outcomes. From multi-variate logistic regression analysis, admission glucose level was a consistent predictor of mortality and morbidity for all AMI patients as well as those who were reperfused. The odds ratios (OR) of in-hospital and 6-month mortality for each 1 mmol/l increment of glucose level were 1.14 (P = 0.002) and 1.18 (P < 0.001) respectively. For patients who underwent reperfusion therapy, the OR of in-hospital and 6-month mortality for each 1 mmol/l increment of glucose level were 1.27 (P = 0.001) and 1.36 (P = 0.001), respectively. We conclude that in the reperfusion era, hyperglycemia is still associated with adverse cardiac outcomes, although it is unclear whether treatment of hyperglycemia will lead to improved outcomes.
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Affiliation(s)
- Vincent W Wong
- Department of Diabetes and Endocrinology, Westmead Hospital, P.O. Box 533, Wentworthville, NSW 2145, Australia.
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Abstract
PURPOSE OF REVIEW The recent publication of the results of an aggressive approach to the treatment of hyperglycaemia in critically ill patients, and a rekindling of interest in the use of an infusion of glucose insulin and potassium as adjunctive therapy in a diverse group of patients with cardiovascular disease, warrants a review of the multiple effects of insulin and a review of laboratory and clinical studies. RECENT FINDINGS The use of an aggressive protocol to maintain normoglycaemia in critically ill patients has been demonstrated to be a beneficial technique in the critical care setting. Implementation of the protocol outside of a research setting appears to be feasible. Recent studies on the use of insulin in addition to glucose and potassium in patients with diverse cardiovascular diseases have also demonstrated positive results. SUMMARY This review will summarize some of the putative beneficial effects of insulin as a pharmacological agent, and review recent clinical data. Although the relative benefits of normoglycaemia in the critical care setting and the beneficial effects of insulin are difficult to differentiate, a substantial overlap exists. The extent to which these converging therapies (aggressive normoglycaemia and insulin pharmacotherapy) will be applicable to diverse clinical settings has yet to be determined.
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Affiliation(s)
- Thomas Solano
- General Intensive Care Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales 2050, Australia.
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Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, Hirsch IB, Hirsh IB. Management of diabetes and hyperglycemia in hospitals. Diabetes Care 2004; 27:553-91. [PMID: 14747243 DOI: 10.2337/diacare.27.2.553] [Citation(s) in RCA: 796] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Stephen Clement
- Department of Endocrinology, Georgetown University Hospital, Washington, DC 20007, USA.
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Wouters PF. New perspectives for an old cure: a glucose-insulin-potassium revival in cardiac surgery? Curr Opin Anaesthesiol 2004; 17:31-3. [PMID: 17021526 DOI: 10.1097/00001503-200402000-00006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
This review discusses the myocardial protective property of the insulin/glucose-insulin-potassium regimen and the mechanisms involved in this beneficial action. Several recent studies suggest that insulin not only is useful to control hyperglycemia and maintain glucose homeostasis but also may have the unique property to protect the myocardium from reperfusion injury and ischemia and prevent apoptosis of myocardial cells. The insulin/glucose-insulin-potassium (GIK) regimen suppresses the production of tumor necrosis factor-alpha, interleukin-6, macrophage migration inhibitory factor and other pro-inflammatory cytokines, and free radicals; and enhances the synthesis of endothelial nitric oxide and anti-inflammatory cytokines interleukin-4 and interleukin-10. Thus, the insulin/GIK regimen brings about its cardioprotective action. This may also explain why the insulin/GIK regimen is useful in sepsis and septic shock, myocardial recovery in acute myocardial infarction, and critical illness. It is suggested that the infusion of adequate amounts of insulin to patients with acute myocardial infarction, congestive heart failure, cardiogenic shock, and critical illness preserves myocardial integrity and function and ensures rapid recovery. In view of the suppressive action of insulin on the synthesis of proinflammatory cytokines and free radicals, it is possible that the insulin/GIK regimen, when used in a timely and appropriate fashion, may also protect other tissues and organs and facilitate in the recovery of patients who are critically ill.
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Affiliation(s)
- Undurti N Das
- EFA Sciences LLC, Norwood, Massachusetts 02062, USA.
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Leverve X. Hyperglycemia and oxidative stress: complex relationships with attractive prospects. Intensive Care Med 2003; 29:511-4. [PMID: 12800829 DOI: 10.1007/s00134-002-1629-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Zuurbier C. Postischemic Myocardial Metabolism. Semin Cardiothorac Vasc Anesth 2003. [DOI: 10.1177/108925320300700112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- C.J. Zuurbier
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105AZ, The Netherlands
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Gao F, Gao E, Yue TL, Ohlstein EH, Lopez BL, Christopher TA, Ma XL. Nitric oxide mediates the antiapoptotic effect of insulin in myocardial ischemia-reperfusion: the roles of PI3-kinase, Akt, and endothelial nitric oxide synthase phosphorylation. Circulation 2002; 105:1497-502. [PMID: 11914261 DOI: 10.1161/01.cir.0000012529.00367.0f] [Citation(s) in RCA: 386] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recent evidence from cultured endothelial cell studies suggests that phosphorylation of endothelial nitric oxide synthase (eNOS) through the PI3-kinase-Akt pathway increases NO production. This study was designed to elucidate the signaling pathway involved in the antiapoptotic effect of insulin in vivo and to test the hypothesis that phosphorylation of eNOS by insulin may participate in the cardioprotective effect of insulin after myocardial ischemia and reperfusion. METHODS AND RESULTS Male Sprague-Dawley rats were subjected to 30 minutes of myocardial ischemia and 4 hours of reperfusion. Rats were randomized to receive vehicle, insulin, insulin plus wortmannin, or insulin plus L-NAME. Treatment with insulin resulted in 2.6-fold and 4.3-fold increases in Akt and eNOS phosphorylation and a significant increase in NO production in ischemic/reperfused myocardial tissue. Phosphorylation of Akt and eNOS and increase of NO production by insulin were completely blocked by wortmannin, a PI3-kinase inhibitor. Pretreatment with L-NAME, a nonselective NOS inhibitor, had no effect on Akt and eNOS phosphorylation but significantly reduced NO production. Moreover, treatment with insulin markedly reduced myocardial apoptotic death (P<0.01 versus vehicle). Pretreatment with wortmannin abolished the antiapoptotic effect of insulin. Most importantly, pretreatment with L-NAME also significantly reduced the antiapoptotic effect of insulin (P<0.01 versus insulin). CONCLUSIONS These results demonstrated that in vivo administration of insulin activated Akt through the PI3-kinase-dependent mechanism and reduced postischemic myocardial apoptotic death. Phosphorylation of eNOS and the concurrent increase of NO production contribute significantly to the antiapoptotic effect of insulin.
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Affiliation(s)
- Feng Gao
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pa, USA
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Abstract
Stress hyperglycemia and diabetes mellitus with myocardial infarction are associated with increased risk for in-hospital mortality, congestive heart failure, or cardiogenic shock. Hyperglycemia triggers free radical generation and suppresses endothelial nitric oxide generation, and thus initiates and perpetuates inflammation. Conversely, insulin suppresses production of tumor necrosis factor-alpha and free radicals, enhances endothelial nitric oxide generation, and improves myocardial function. It is proposed that the balance between insulin and plasma glucose levels is critical to recovery and/or complications that occur following acute myocardial infarction and in the critically ill. Adequate attention should be given to maintaining euglycemia (plasma glucose <or= 110 mg/dl) in order to reduce infarct size and improve cardiac function while using a glucose-insulin-potassium cocktail.
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Massion PB, Moniotte S, Balligand JL. Nitric oxide: does it play a role in the heart of the critically ill? Curr Opin Crit Care 2001; 7:323-36. [PMID: 11805529 DOI: 10.1097/00075198-200110000-00003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Nitric oxide regulates many aspects of myocardial function, not only in the normal heart but also in ischemic and nonischemic heart failure, septic cardiomyopathy, cardiac allograft rejection, and myocarditis. Accumulating evidence implicates the endogenous production of nitric oxide in the regulation of myocardial contractility, distensibility, heart rate, coronary vasodilation, myocardial oxygen consumption, mitochondrial respiration, and apoptosis. The effects of nitric oxide promote left ventricular mechanical efficiency, ie, appropriate matching between cardiac work and myocardial oxygen consumption. Most of these beneficial effects are attributed to the low physiologic concentrations generated by the constitutive endothelial or neuronal nitric oxide synthase. By contrast, inducible nitric oxide synthase generates larger concentrations of nitric oxide over longer periods of time, leading to mostly detrimental effects. In addition, the recently identified beta3-adrenoceptor mediates a negative inotropic effect through coupling to endothelial nitric oxide synthase and is overexpressed in heart failure. An imbalance between beta 1 and beta2-adrenoceptor and beta3-adrenoceptor, with a prevailing influence of beta3-adrenoceptor, may play a causal role in the pathogenesis of cardiac diseases such as terminal heart failure. Likewise, changes in the expression of endothelial nitric oxide synthase or inducible nitric oxide synthase within the myocardium may alter the delicate balance between the effects of nitric oxide produced by either of these isoforms. New treatments such as selective inducible nitric oxide synthase blockade, endothelial nitric oxide synthase promoting therapies, and selective beta3-adrenoceptor modulators may offer promising new therapeutic approaches to optimize the care of critically ill patients according to their stage and specific underlying disease process.
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Affiliation(s)
- P B Massion
- Department of Internal Medicine, Unit of Pharmacology and Therapeutics, Université catholique de Louvain, Brussels, Belgium
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