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Boyd W, Young W, Yildiz M, Henry TD, Gorder K. In-hospital cardiac arrest after STEMI: prevention strategies and post-arrest care. Expert Rev Cardiovasc Ther 2024; 22:379-389. [PMID: 39076105 DOI: 10.1080/14779072.2024.2383648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 07/19/2024] [Indexed: 07/31/2024]
Abstract
INTRODUCTION In-Hospital Cardiac Arrest (IHCA) after ST-segment Elevation Myocardial Infarction (STEMI) is a subset of IHCA with high morbidity. While information on this selected group of patients is limited, closer inspection reveals that this is a challenging patient population with certain risk factors for IHCA following treatment of STEMI. AREAS COVERED In this review article, strategies for prevention of IHCA post STEMI are reviewed, as well as best-practices for the care of STEMI patients post-IHCA. EXPERT OPINION Early and successful reperfusion is key for the prevention of IHCA and has a significant impact on in-hospital mortality. A number of pharmacological treatments have also been studied that can impact the progression to IHCA. Development of cardiogenic shock post-STEMI increases mortality and raises the risk of cardiac arrest. The treatment of IHCA follows the ACLS algorithm with some notable exceptions.
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Affiliation(s)
- Walker Boyd
- Heart and Vascular Institute, The Christ Hospital, Cincinnati, Ohio, USA
| | - Wesley Young
- Heart and Vascular Institute, The Christ Hospital, Cincinnati, Ohio, USA
| | - Mehmet Yildiz
- Heart and Vascular Institute, The Christ Hospital, Cincinnati, Ohio, USA
| | - Timothy D Henry
- Heart and Vascular Institute, The Christ Hospital, Cincinnati, Ohio, USA
- The Carl and Edyth Lindner Research Center at The Christ Hospital, Cincinnati, Ohio, USA
| | - Kari Gorder
- Heart and Vascular Institute, The Christ Hospital, Cincinnati, Ohio, USA
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2
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Li M, Zheng C, Kawada T, Uemura K, Inagaki M, Saku K, Sugimachi M. Early donepezil monotherapy or combination with metoprolol significantly prevents subsequent chronic heart failure in rats with reperfused myocardial infarction. J Physiol Sci 2022; 72:12. [PMID: 35725377 PMCID: PMC10717938 DOI: 10.1186/s12576-022-00836-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/24/2022] [Indexed: 11/10/2022]
Abstract
Despite the presence of clinical guidelines recommending that β-blocker treatment be initiated early after reperfused myocardial infarction (RMI), acute myocardial infarction remains a leading cause of chronic heart failure (CHF). In this study, we compared the effects of donepezil, metoprolol, and their combination on the progression of cardiac remodeling in rats with RMI. The animals were randomly assigned to untreated (UT), donepezil-treated (DT), metoprolol-treated (MT), and a combination of donepezil and metoprolol (DMT) groups. On day 8 after surgery, compared to the UT, the DT and DMT significantly improved myocardial salvage, owing to the suppression of macrophage infiltration and apoptosis. After the 10-week treatment, the DT and DMT exhibited decreased heart rate, reduced myocardial infarct size, attenuated cardiac dysfunction, and decreased plasma levels of brain natriuretic peptide and catecholamine, thereby preventing subsequent CHF. These results suggest that donepezil monotherapy or combined therapy with β-blocker may be an alternative pharmacotherapy post-RMI.
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Affiliation(s)
- Meihua Li
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
| | - Can Zheng
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kazunori Uemura
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Masashi Inagaki
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
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3
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Fabris E, Hermanides R, Roolvink V, Ibanez B, Ottervanger JP, Pizarro G, van Royen N, Mateos-Rodriguez A, Dambrink JH, Albarran A, Fernández-Avilés F, Botas J, Remkes W, Hernandez-Jaras V, Kedhi E, Zamorano J, Alfonso F, García-Lledó A, van Leeuwen M, Nijveldt R, Postma S, Kolkman E, Gosselink M, de Smet B, Rasoul S, Lipsic E, Piek JJ, Fuster V, van 't Hof AW. Beta-blocker effect on ST-segment: a prespecified analysis of the EARLY-BAMI randomised trial. Open Heart 2021; 7:openhrt-2020-001316. [PMID: 33318150 PMCID: PMC7737101 DOI: 10.1136/openhrt-2020-001316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 09/06/2020] [Accepted: 10/23/2020] [Indexed: 11/13/2022] Open
Abstract
Objective The effect of early intravenous (IV) beta-blockers (BBs) administration in patients undergoing primary percutaneous coronary intervention (pPCI) on ST-segment deviation is unknown. We undertook a prespecified secondary analysis of the Early Beta-blocker Administration before primary PCI in patients with
ST-elevation Myocardial Infarction (EARLY-BAMI) trial to investigate the effect of early IV BB on ST-segment deviation. Methods The EARLY-BAMI trial randomised patients with ST-elevation myocardial infarction (STEMI) to IV metoprolol (2×5 mg bolus) or matched placebo before pPCI. The prespecified outcome, evaluated by an independent core laboratory blinded to study treatment, was the residual ST-segment deviation 1 hour after pPCI (ie, the percentage of patients with >3 mm cumulative ST deviation at 1 hour after pPCI). Results An ECG for the evaluation of residual ST-segment deviation 1 hour after pPCI was available in 442 out of 683 randomised patients. The BB group had a lower heart rate after pPCI compared with placebo (71.2±13.2 vs 74.3±13.6, p=0.016); however, no differences were noted in the percentages of patients with >3 mm cumulative ST deviation at 1 hour after pPCI (58.6% vs 54.1%, p=0.38, in BB vs placebo, respectively) neither a significant difference was found for the percentages of patients in each of the four prespecified groups (normalised ST-segment; 1–3 mm; 4–6 mm;>6 mm residual ST-deviation). Conclusions In patients with STEMI, who were being transported for primary PCI, early IV BB administration did not significantly affect ST-segment deviation after pPCI compared with placebo. The neutral result of early IV BB administration on an early marker of pharmacological effect is consistent with the absence of subsequent improvement of clinical outcomes.
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Affiliation(s)
- Enrico Fabris
- Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands .,Cardiovascular Department, University of Trieste, Trieste, Italy
| | | | - Vincent Roolvink
- Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,IIS-Fundación Jiménez Díaz, Madrid, Spain.,CIBERCV, Madrid, Spain
| | | | - Gonzalo Pizarro
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,CIBERCV, Madrid, Spain.,Hospital Ruber Juan Bravo UEM, Madrid, Spain
| | - Niels van Royen
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Alonso Mateos-Rodriguez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,Facultad de Medicina. Universidad Francisco de Vitoria, Madrid, Spain
| | - Jan Henk Dambrink
- Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands
| | - Agustin Albarran
- Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Francisco Fernández-Avilés
- CIBERCV, Madrid, Spain.,Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain.,ISCIII, Madrid, Spain
| | - Javier Botas
- Servicio de Cardiologia, Hospital Universitario Fundacion Alcorcon, Madrid, Spain
| | | | | | - Elvin Kedhi
- Erasmus Hospital, Université libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Jose Zamorano
- CIBERCV, Madrid, Spain.,University Hopsital Ramon y Cajal, Madrid, Spain
| | - Fernando Alfonso
- Department of Cardiology, Hospital Universitario de la Princesa, Madrid, Spain
| | - Alberto García-Lledó
- Department of Cardiology, Hospital Príncipe de Asturias, Alcala de Henares, Madrid, Spain
| | | | | | | | | | - Marcel Gosselink
- Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands
| | - Bart de Smet
- Department of Cardiology, Meander Medisch Centrum, Amersfoort, The Netherlands
| | - Saman Rasoul
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.,Zuyderland Medical Centre Heerlen, Heerlen, Limburg, The Netherlands
| | - Erik Lipsic
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan J Piek
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
| | - Valentin Fuster
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,Mount Sinai School Medicine, New York, New York, USA
| | - Arnoud Wj van 't Hof
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.,Zuyderland Medical Centre Heerlen, Heerlen, Limburg, The Netherlands
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Clemente-Moragón A, Gómez M, Villena-Gutiérrez R, Lalama DV, García-Prieto J, Martínez F, Sánchez-Cabo F, Fuster V, Oliver E, Ibáñez B. Metoprolol exerts a non-class effect against ischaemia-reperfusion injury by abrogating exacerbated inflammation. Eur Heart J 2021; 41:4425-4440. [PMID: 33026079 PMCID: PMC7752252 DOI: 10.1093/eurheartj/ehaa733] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/11/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023] Open
Abstract
Aims Clinical guidelines recommend early intravenous β-blockers during ongoing myocardial infarction; however, it is unknown whether all β-blockers exert a similar cardioprotective effect. We experimentally compared three clinically approved intravenous β-blockers. Methods and results Mice undergoing 45 min/24 h ischaemia–reperfusion (I/R) received vehicle, metoprolol, atenolol, or propranolol at min 35. The effect on neutrophil infiltration was tested in three models of exacerbated inflammation. Neutrophil migration was evaluated in vitro and in vivo by intravital microscopy. The effect of β-blockers on the conformation of the β1 adrenergic receptor was studied in silico. Of the tested β-blockers, only metoprolol ameliorated I/R injury [infarct size (IS) = 18.0% ± 0.03% for metoprolol vs. 35.9% ± 0.03% for vehicle; P < 0.01]. Atenolol and propranolol had no effect on IS. In the three exacerbated inflammation models, neutrophil infiltration was significantly attenuated only in the presence of metoprolol (60%, 50%, and 70% reductions vs. vehicle in myocardial I/R injury, thioglycolate-induced peritonitis, and lipopolysaccharide-induced acute lung injury, respectively). Migration studies confirmed the particular ability of metoprolol to disrupt neutrophil dynamics. In silico analysis indicated different intracellular β1 adrenergic receptor conformational changes when bound to metoprolol than to the other two β-blockers. Conclusions Metoprolol exerts a disruptive action on neutrophil dynamics during exacerbated inflammation, resulting in an infarct-limiting effect not observed with atenolol or propranolol. The differential effect of β-blockers may be related to distinct conformational changes in the β1 adrenergic receptor upon metoprolol binding. If these data are confirmed in a clinical trial, metoprolol should become the intravenous β-blocker of choice for patients with ongoing infarction. ![]()
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Affiliation(s)
- Agustín Clemente-Moragón
- Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), c/Melchor Fernandez Almagro, 3. 28029 Madrid, Spain
| | - Mónica Gómez
- Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), c/Melchor Fernandez Almagro, 3. 28029 Madrid, Spain
| | - Rocío Villena-Gutiérrez
- Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), c/Melchor Fernandez Almagro, 3. 28029 Madrid, Spain
| | - Doménica V Lalama
- Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), c/Melchor Fernandez Almagro, 3. 28029 Madrid, Spain
| | - Jaime García-Prieto
- Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), c/Melchor Fernandez Almagro, 3. 28029 Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, C/ Monforte de Lemos 3-5. Pabellón 11. Planta 0 28029 Madrid, Spain
| | - Fernando Martínez
- Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), c/Melchor Fernandez Almagro, 3. 28029 Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, C/ Monforte de Lemos 3-5. Pabellón 11. Planta 0 28029 Madrid, Spain
| | - Fátima Sánchez-Cabo
- Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), c/Melchor Fernandez Almagro, 3. 28029 Madrid, Spain
| | - Valentín Fuster
- Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), c/Melchor Fernandez Almagro, 3. 28029 Madrid, Spain.,Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicina at Mount Sinai School, 1 Gustave L. Levy Place. 10029-5674 New York, NY, USA
| | - Eduardo Oliver
- Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), c/Melchor Fernandez Almagro, 3. 28029 Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, C/ Monforte de Lemos 3-5. Pabellón 11. Planta 0 28029 Madrid, Spain
| | - Borja Ibáñez
- Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), c/Melchor Fernandez Almagro, 3. 28029 Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, C/ Monforte de Lemos 3-5. Pabellón 11. Planta 0 28029 Madrid, Spain.,Department of Cardiology, Instituto de Investigación Sanitaria (IIS)-Fundación Jiménez Díaz, Calle Isaac Peral, 42. 28015 Madrid, Spain
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5
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Abstract
PURPOSE OF REVIEW Controversy exists whether beta-blockers should be given before primary percutaneous coronary intervention (PCI) or to defer their administration for up to 24 hours. RECENT FINDINGS Animal studies, most of them conducted in the 1970s and 1980s, showed evidence that early beta-blocker administration may reduce infarct size. Subsequent human studies had mixed results on infarct size and survival. More specifically, in the current primary PCI era, only four studies evaluated the impact of early intravenous beta-blocker administration after acute myocardial infarction, only two of them before PCI. All studies agree that in hemodynamically stable patients, early intravenous beta-blocker administration is safe and protected against malignant arrhythmias. Nevertheless, results on infarct size and mortality are equivocal. Considering the heterogeneity of currently available data, further studies are still needed to assess the benefit of early injection of metoprolol in STEMI patients in a large double-blinded and randomized design versus placebo.
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Affiliation(s)
- Georgios Giannakopoulos
- Cardiology Division, Department of Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Stephane Noble
- Cardiology Division, Department of Medicine, University Hospital of Geneva, Geneva, Switzerland
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6
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Oyama Y, Blaskowsky J, Eckle T. Dose-dependent Effects of Esmolol-epinephrine Combination Therapy in Myocardial Ischemia and Reperfusion Injury. Curr Pharm Des 2020; 25:2199-2206. [PMID: 31258066 DOI: 10.2174/1381612825666190618124829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 06/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Animal studies on cardiac arrest found that a combination of epinephrine with esmolol attenuates post-resuscitation myocardial dysfunction. Based on these findings, we hypothesized that esmololepinephrine combination therapy would be superior to a reported cardioprotective esmolol therapy alone in a mouse model of myocardial ischemia and reperfusion (IR) injury. METHODS C57BL/6J mice were subjected to 60 min of myocardial ischemia and 120 min of reperfusion. Mice received either saline, esmolol (0.4 mg/kg/h), epinephrine (0.05 mg/kg/h), or esmolol combined with epinephrine (esmolol: 0.4 mg/kg/h or 0.8 mg/kg/h and epinephrine: 0.05 mg/kg/h) during reperfusion. After reperfusion, infarct sizes in the area-at-risk and serum cardiac troponin-I levels were determined. Hemodynamic effects of drugs infused were determined by measurements of heart rate (HR) and mean arterial blood pressure (MAP) via a carotid artery catheter. RESULTS Esmolol during reperfusion resulted in robust cardioprotection (esmolol vs. saline: 24.3±8% vs. 40.6±3% infarct size), which was abolished by epinephrine co-administration (38.1±15% infarct size). Increasing the esmolol dose, however, was able to restore esmolol-cardioprotection in the epinephrine-esmolol (18.6±8% infarct size) co-treatment group with improved hemodynamics compared to the esmolol group (epinephrine-esmolol vs. esmolol: MAP 80 vs. 75 mmHg, HR 452 vs. 402 beats/min). CONCLUSION These results confirm earlier studies on esmolol-cardioprotection from myocardial IR-injury and demonstrate that a dose optimized epinephrine-esmolol co-treatment maintains esmolol-cardioprotection with improved hemodynamics compared to esmolol treatment alone. These findings might have implications for current clinical practice in hemodynamically unstable patients suffering from myocardial ischemia.
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Affiliation(s)
- Yoshimasa Oyama
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045, United States
| | - Justin Blaskowsky
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045, United States
| | - Tobias Eckle
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045, United States
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7
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Maslov LN, Tsibulnikov SY, Prokudina ES, Popov SV, Boshchenko AA, Singh N, Zhang Y, Oeltgen PR. Trigger, Signaling Mechanism and End Effector of Cardioprotective Effect of Remote Postconditioning of Heart. Curr Cardiol Rev 2019; 15:177-187. [PMID: 30813880 PMCID: PMC6719390 DOI: 10.2174/1573403x15666190226095820] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/15/2019] [Accepted: 02/18/2019] [Indexed: 11/22/2022] Open
Abstract
The hypothetical trigger of remote postconditioning (RPost) of the heart is the high-molecular weight hydrophobic peptide(s). Nitric oxide and adenosine serve as intermediaries between the peptide and intracellular structures. The role of the autonomic nervous system in RPost requires further study. In signaling mechanism RPost, kinases are involved: protein kinase C, PI3, Akt, JAK. The hypothetical end effector of RPost is aldehyde dehydrogenase-2, the transcription factors STAT, Nrf2, and also the BKCa channel.
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Affiliation(s)
- Leonid N Maslov
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Science, Tomsk, Russian Federation
| | - Sergey Y Tsibulnikov
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Science, Tomsk, Russian Federation
| | - Ekaterina S Prokudina
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Science, Tomsk, Russian Federation
| | - Sergey V Popov
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Science, Tomsk, Russian Federation
| | - Alla A Boshchenko
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Science, Tomsk, Russian Federation
| | - Nirmal Singh
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, India
| | - Yi Zhang
- Department of Physiology, Hebei Medical University, Shijiazhuang, China
| | - Peter R Oeltgen
- Department of Pathology, University of Kentucky College of Medicine, Lexington, KY, United States
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8
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Hoedemaker NP, Roolvink V, de Winter RJ, van Royen N, Fuster V, García-Ruiz JM, Er F, Gassanov N, Hanada K, Okumura K, Ibáñez B, van 't Hof AW, Damman P. Early intravenous beta-blockers in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: A patient-pooled meta-analysis of randomized clinical trials. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 9:469-477. [PMID: 30759994 PMCID: PMC7672673 DOI: 10.1177/2048872619830609] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Conflicting evidence is available on the efficacy and safety of early intravenous beta-blockers before primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. We performed a patient-pooled meta-analysis of trials comparing early intravenous beta-blockers with placebo or routine care in ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention. AIM The aim of this study was to evaluate the clinical and safety outcomes of intravenous beta-blockers in ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention. METHODS Four randomized trials with a total of 1150 patients were included. The main outcome was one-year death or myocardial infarction. Secondary outcomes included biomarker-based infarct size, left ventricular ejection fraction during follow-up, ventricular tachycardia, and a composite safety outcome (cardiogenic shock, symptomatic bradycardia, or hypotension) during hospitalization. RESULTS One-year death or myocardial infarction was similar among beta-blocker (4.2%) and control patients (4.4%) (hazard ratio: 0.96 (95% confidence interval: 0.53-1.75, p=0.90, I2=0%). No difference was observed in biomarker-based infarct size. One-month left ventricular ejection fraction was similar, but left ventricular ejection fraction at six months was significantly higher in patients treated with early intravenous beta-blockade (52.8% versus 50.0% in the control group, p=0.03). No difference was observed in the composite safety outcome or ventricular tachycardia during hospitalization. CONCLUSION In ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention, the administration of early intravenous beta-blockers was safe. However, there was no difference in the main outcome of one-year death or myocardial infarction with early intravenous beta-blockers. A larger clinical trial is warranted to confirm the definitive efficacy of early intravenous beta-blockers.
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Affiliation(s)
| | | | | | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, The Netherlands
| | - Valentin Fuster
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, USA.,Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Spain
| | - José M García-Ruiz
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Fikret Er
- Department of Cardiology and Electrophysiology, Klinikum Gütersloh, Germany
| | - Natig Gassanov
- Department of Cardiology and Electrophysiology, Klinikum Gütersloh, Germany
| | - Kenji Hanada
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Japan
| | - Borja Ibáñez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain.,Cardiology Department, IIS-Fundacion Jiménez Díaz University Hospital, Spain
| | - Arnoud W van 't Hof
- Department of Cardiology, Maastricht University Medical Center, The Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Center, The Netherlands
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9
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β-Blockers in myocardial infarction and coronary artery disease with a preserved ejection fraction. Coron Artery Dis 2018; 29:262-270. [DOI: 10.1097/mca.0000000000000610] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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10
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Santucci A, Cavallini C. Favorable effects of intravenous beta blockers in ST elevation myocardial infarct. J Cardiovasc Med (Hagerstown) 2018. [DOI: 10.2459/jcm.0000000000000553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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11
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Davies JMS, Cillard J, Friguet B, Cadenas E, Cadet J, Cayce R, Fishmann A, Liao D, Bulteau AL, Derbré F, Rébillard A, Burstein S, Hirsch E, Kloner RA, Jakowec M, Petzinger G, Sauce D, Sennlaub F, Limon I, Ursini F, Maiorino M, Economides C, Pike CJ, Cohen P, Salvayre AN, Halliday MR, Lundquist AJ, Jakowec NA, Mechta-Grigoriou F, Mericskay M, Mariani J, Li Z, Huang D, Grant E, Forman HJ, Finch CE, Sun PY, Pomatto LCD, Agbulut O, Warburton D, Neri C, Rouis M, Cillard P, Capeau J, Rosenbaum J, Davies KJA. The Oxygen Paradox, the French Paradox, and age-related diseases. GeroScience 2017; 39:499-550. [PMID: 29270905 PMCID: PMC5745211 DOI: 10.1007/s11357-017-0002-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 11/09/2017] [Indexed: 02/06/2023] Open
Abstract
A paradox is a seemingly absurd or impossible concept, proposition, or theory that is often difficult to understand or explain, sometimes apparently self-contradictory, and yet ultimately correct or true. How is it possible, for example, that oxygen "a toxic environmental poison" could be also indispensable for life (Beckman and Ames Physiol Rev 78(2):547-81, 1998; Stadtman and Berlett Chem Res Toxicol 10(5):485-94, 1997)?: the so-called Oxygen Paradox (Davies and Ursini 1995; Davies Biochem Soc Symp 61:1-31, 1995). How can French people apparently disregard the rule that high dietary intakes of cholesterol and saturated fats (e.g., cheese and paté) will result in an early death from cardiovascular diseases (Renaud and de Lorgeril Lancet 339(8808):1523-6, 1992; Catalgol et al. Front Pharmacol 3:141, 2012; Eisenberg et al. Nat Med 22(12):1428-1438, 2016)?: the so-called, French Paradox. Doubtless, the truth is not a duality and epistemological bias probably generates apparently self-contradictory conclusions. Perhaps nowhere in biology are there so many apparently contradictory views, and even experimental results, affecting human physiology and pathology as in the fields of free radicals and oxidative stress, antioxidants, foods and drinks, and dietary recommendations; this is particularly true when issues such as disease-susceptibility or avoidance, "healthspan," "lifespan," and ageing are involved. Consider, for example, the apparently paradoxical observation that treatment with low doses of a substance that is toxic at high concentrations may actually induce transient adaptations that protect against a subsequent exposure to the same (or similar) toxin. This particular paradox is now mechanistically explained as "Adaptive Homeostasis" (Davies Mol Asp Med 49:1-7, 2016; Pomatto et al. 2017a; Lomeli et al. Clin Sci (Lond) 131(21):2573-2599, 2017; Pomatto and Davies 2017); the non-damaging process by which an apparent toxicant can activate biological signal transduction pathways to increase expression of protective genes, by mechanisms that are completely different from those by which the same agent induces toxicity at high concentrations. In this review, we explore the influences and effects of paradoxes such as the Oxygen Paradox and the French Paradox on the etiology, progression, and outcomes of many of the major human age-related diseases, as well as the basic biological phenomenon of ageing itself.
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Affiliation(s)
- Joanna M S Davies
- The Medical Group, Internal Medicine, Rheumatology & Osteoporosis, Dermatology, Pulmonology, Ophthalmology, and Cardiology; the Hospital of the Good Samaritan, Los Angeles, CA, 90017, USA
- Leonard Davis School of Gerontology of the Ethel Percy Andrus Gerontology Center, University of Southern California, Los Angeles, CA, 90089-0191, USA
| | - Josiane Cillard
- Lab de Biologie Cellulaire et Végétale, Faculté de Pharmacie, Université de Rennes, 35043, Rennes Cedex, France
| | - Bertrand Friguet
- Institut de Biologie Paris-Seine (IBPS), UMR CNRS 8256, Biological Adaptation and Ageing, Sorbonne Universités, UPMC Univ Paris 06, 75005, Paris, France
- INSERM ERL U1164, 75005, Paris, France
| | - Enrique Cadenas
- Leonard Davis School of Gerontology of the Ethel Percy Andrus Gerontology Center, University of Southern California, Los Angeles, CA, 90089-0191, USA
- School of Pharmacy, University of Southern California, Los Angeles, CA, 90089-9121, USA
- Department of Biochemistry & Molecular Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, 90033, USA
| | - Jean Cadet
- Département de Médecine nucléaire et Radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Québec, J1H 5N4, Canada
| | - Rachael Cayce
- The Medical Group, Internal Medicine, Rheumatology & Osteoporosis, Dermatology, Pulmonology, Ophthalmology, and Cardiology; the Hospital of the Good Samaritan, Los Angeles, CA, 90017, USA
| | - Andrew Fishmann
- The Medical Group, Internal Medicine, Rheumatology & Osteoporosis, Dermatology, Pulmonology, Ophthalmology, and Cardiology; the Hospital of the Good Samaritan, Los Angeles, CA, 90017, USA
| | - David Liao
- The Medical Group, Internal Medicine, Rheumatology & Osteoporosis, Dermatology, Pulmonology, Ophthalmology, and Cardiology; the Hospital of the Good Samaritan, Los Angeles, CA, 90017, USA
| | - Anne-Laure Bulteau
- Institut de Génomique Fonctionnelle de Lyon,ENS de Lyon, CNRS, 69364, Lyon Cedex 07, France
| | - Frédéric Derbré
- Laboratory for Movement, Sport and Health Sciences-EA 1274, M2S, Université de Rennes 2-ENS, Bruz, 35170, Rennes, France
| | - Amélie Rébillard
- Laboratory for Movement, Sport and Health Sciences-EA 1274, M2S, Université de Rennes 2-ENS, Bruz, 35170, Rennes, France
| | - Steven Burstein
- The Medical Group, Internal Medicine, Rheumatology & Osteoporosis, Dermatology, Pulmonology, Ophthalmology, and Cardiology; the Hospital of the Good Samaritan, Los Angeles, CA, 90017, USA
| | - Etienne Hirsch
- INSERM UMR 1127-CNRS UMR 7225, Institut du cerveau et de la moelle épinière-ICM Thérapeutique Expérimentale de la Maladie de Parkinson, Université Pierre et Marie Curie, 75651, Paris Cedex 13, France
| | - Robert A Kloner
- Huntington Medical Research Institutes, Pasadena, CA, 91105, USA
| | - Michael Jakowec
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Giselle Petzinger
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Delphine Sauce
- Chronic infections and Immune ageing, INSERM U1135, Hopital Pitie-Salpetriere, Pierre et Marie Curie University, 75013, Paris, France
| | | | - Isabelle Limon
- Institut de Biologie Paris-Seine (IBPS), UMR CNRS 8256, Biological Adaptation and Ageing, Sorbonne Universités, UPMC Univ Paris 06, 75005, Paris, France
| | - Fulvio Ursini
- Department of Molecular Medicine, University of Padova, 35121, Padova, Italy
| | - Matilde Maiorino
- Department of Molecular Medicine, University of Padova, 35121, Padova, Italy
| | - Christina Economides
- Los Angeles Cardiology Associates, Hospital of the Good Samaritan, Los Angeles, CA, 90017, USA
| | - Christian J Pike
- Leonard Davis School of Gerontology of the Ethel Percy Andrus Gerontology Center, University of Southern California, Los Angeles, CA, 90089-0191, USA
- Division of Neurobiology, Department of Biological Sciences of the Dornsife College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, CA, 90089-0191, USA
| | - Pinchas Cohen
- Leonard Davis School of Gerontology of the Ethel Percy Andrus Gerontology Center, University of Southern California, Los Angeles, CA, 90089-0191, USA
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, 90033, USA
| | - Anne Negre Salvayre
- Lipid peroxidation, Signalling and Vascular Diseases INSERM U1048, 31432, Toulouse Cedex 4, France
| | - Matthew R Halliday
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Adam J Lundquist
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Nicolaus A Jakowec
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | | | - Mathias Mericskay
- Laboratoire de Signalisation et Physiopathologie Cardiovasculaire-Inserm UMR-S 1180, Faculté de Pharmacie, Université Paris-Sud, 92296 Châtenay-Malabry, Paris, France
| | - Jean Mariani
- Institut de Biologie Paris-Seine (IBPS), UMR CNRS 8256, Biological Adaptation and Ageing, Sorbonne Universités, UPMC Univ Paris 06, 75005, Paris, France
| | - Zhenlin Li
- Institut de Biologie Paris-Seine (IBPS), UMR CNRS 8256, Biological Adaptation and Ageing, Sorbonne Universités, UPMC Univ Paris 06, 75005, Paris, France
- INSERM ERL U1164, 75005, Paris, France
| | - David Huang
- Department of Radiation Oncology, Hospital of the Good Samaritan, Los Angeles, CA, 90017, USA
| | - Ellsworth Grant
- Department of Oncology & Hematology, Hospital of the Good Samaritan, Los Angeles, CA, 90017, USA
| | - Henry J Forman
- Leonard Davis School of Gerontology of the Ethel Percy Andrus Gerontology Center, University of Southern California, Los Angeles, CA, 90089-0191, USA
| | - Caleb E Finch
- Leonard Davis School of Gerontology of the Ethel Percy Andrus Gerontology Center, University of Southern California, Los Angeles, CA, 90089-0191, USA
- Los Angeles Cardiology Associates, Hospital of the Good Samaritan, Los Angeles, CA, 90017, USA
- Division of Molecular & Computational Biology, Department of Biological Sciences of the Dornsife College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, CA, 90089-0191, USA
| | - Patrick Y Sun
- Leonard Davis School of Gerontology of the Ethel Percy Andrus Gerontology Center, University of Southern California, Los Angeles, CA, 90089-0191, USA
- Division of Molecular & Computational Biology, Department of Biological Sciences of the Dornsife College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, CA, 90089-0191, USA
| | - Laura C D Pomatto
- Leonard Davis School of Gerontology of the Ethel Percy Andrus Gerontology Center, University of Southern California, Los Angeles, CA, 90089-0191, USA
- Division of Molecular & Computational Biology, Department of Biological Sciences of the Dornsife College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, CA, 90089-0191, USA
| | - Onnik Agbulut
- Institut de Biologie Paris-Seine (IBPS), UMR CNRS 8256, Biological Adaptation and Ageing, Sorbonne Universités, UPMC Univ Paris 06, 75005, Paris, France
| | - David Warburton
- Children's Hospital of Los Angeles, Developmental Biology, Regenerative Medicine and Stem Cell Therapeutics program and the Center for Environmental Impact on Global Health Across the Lifespan at The Saban Research Institute, Los Angeles, CA, 90027, USA
- Department of Pediatrics, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, 90033, USA
| | - Christian Neri
- Institut de Biologie Paris-Seine (IBPS), UMR CNRS 8256, Biological Adaptation and Ageing, Sorbonne Universités, UPMC Univ Paris 06, 75005, Paris, France
| | - Mustapha Rouis
- Institut de Biologie Paris-Seine (IBPS), UMR CNRS 8256, Biological Adaptation and Ageing, Sorbonne Universités, UPMC Univ Paris 06, 75005, Paris, France
- INSERM ERL U1164, 75005, Paris, France
| | - Pierre Cillard
- Lab de Biologie Cellulaire et Végétale, Faculté de Pharmacie, Université de Rennes, 35043, Rennes Cedex, France
| | - Jacqueline Capeau
- DR Saint-Antoine UMR_S938, UPMC, Inserm Faculté de Médecine, Université Pierre et Marie Curie, 75012, Paris, France
| | - Jean Rosenbaum
- Scientific Service of the Embassy of France in the USA, Consulate General of France in Los Angeles, Los Angeles, CA, 90025, USA
| | - Kelvin J A Davies
- Leonard Davis School of Gerontology of the Ethel Percy Andrus Gerontology Center, University of Southern California, Los Angeles, CA, 90089-0191, USA.
- Department of Biochemistry & Molecular Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, 90033, USA.
- Division of Molecular & Computational Biology, Department of Biological Sciences of the Dornsife College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, CA, 90089-0191, USA.
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Mohammad M, Andell P, Koul S, Desta L, Jernberg T, Omerovic E, Spaak J, Fröbert O, Jensen J, Engstrøm T, Hofman-Bang C, Persson H, Erlinge D. Intravenous beta-blocker therapy in ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention is not associated with benefit regarding short-term mortality: a Swedish nationwide observational study. EUROINTERVENTION 2017; 13:e210-e218. [DOI: 10.4244/eij-d-16-01021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
The size of the myocardial infarction remains an important therapeutic target, because heart attack size correlates with mortality and heart failure. In this era, myocardial infarct size is reduced primarily by timely reperfusion of the infarct related coronary artery. Whereas numerous pre-clinical studies have shown that certain pharmacologic agents and therapeutic maneuvers reduce myocardial infarction size greater than reperfusion alone, very few of these therapies have translated to successful clinical trials or standard clinical use. In this review we discuss both the recent successes as well as recent disappointments, and describe some of the newer potential therapies from the preclinical literature that have not yet been tested in clinical trials.
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Elgendy IY, Elgendy AY, Mahmoud AN, Mansoor H, Mojadidi MK, Bavry AA. Intravenous β-blockers for patients undergoing primary percutaneous coronary intervention: A meta-analysis of randomized trials. Int J Cardiol 2016; 223:891-897. [PMID: 27584567 DOI: 10.1016/j.ijcard.2016.08.293] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 08/18/2016] [Indexed: 01/03/2023]
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15
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Zhu BQ, Simonis U, Cecchini G, Zhou HZ, Li L, Teerlink JR, Karliner JS. Comparison of Pyrroloquinoline Quinone and/or Metoprolol on Myocardial Infarct Size and Mitochondrial Damage in a Rat Model of Ischemia/Reperfusion Injury. J Cardiovasc Pharmacol Ther 2016; 11:119-28. [PMID: 16891289 DOI: 10.1177/1074248406288757] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The cardioprotective effectiveness of low-dose pyrroloquinoline quinone (PQQ, 3 mg/kg) was compared with metoprolol, a β1-selective adrenoceptor antagonist. Rats underwent 30 minutes of left anterior descending coronary artery occlusion and 2 hours of reperfusion. Metoprolol and/or PQQ were given at the onset of reperfusion to mimic clinical treatment. Metoprolol and/or PQQ reduced infarct size and protected against ischemia-induced left ventricular dysfunction after 2 hours of reper-fusion. Combined therapy augmented left ventricular developed pressure at the end of reperfusion. Metoprolol or PQQ alone enhanced mitochondrial respiratory ratios in ischemic and nonischemic myocardium. Although the PQQ/metoprolol combination therapy increased respiratory ratio values, the effects were small when compared with PQQ alone. Only PQQ decreased lipid peroxidation. Metoprolol and/or PQQ given at the onset of reperfusion reduce infarct size and improve cardiac function. Combination therapy further reduces infarct size. PQQ is superior to metoprolol in protecting mitochondria from ischemia/reperfusion oxidative damage
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Affiliation(s)
- Bo-qing Zhu
- Cardiology Section, VA Medical Center, Department of Medicine, University of California-San Francisco, 4150 Clement Street, San Francisco, CA 94121, USA
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16
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Intravenous Beta-Blockade for Limiting Myocardial Infarct Size. J Am Coll Cardiol 2016; 67:2105-2107. [DOI: 10.1016/j.jacc.2016.02.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 02/26/2016] [Indexed: 11/17/2022]
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17
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Roolvink V, Ibáñez B, Ottervanger JP, Pizarro G, van Royen N, Mateos A, Dambrink JHE, Escalera N, Lipsic E, Albarran A, Fernández-Ortiz A, Fernández-Avilés F, Goicolea J, Botas J, Remkes W, Hernandez-Jaras V, Kedhi E, Zamorano JL, Navarro F, Alfonso F, García-Lledó A, Alonso J, van Leeuwen M, Nijveldt R, Postma S, Kolkman E, Gosselink M, de Smet B, Rasoul S, Piek JJ, Fuster V, van 't Hof AWJ. Early Intravenous Beta-Blockers in Patients With ST-Segment Elevation Myocardial Infarction Before Primary Percutaneous Coronary Intervention. J Am Coll Cardiol 2016; 67:2705-2715. [PMID: 27050189 DOI: 10.1016/j.jacc.2016.03.522] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 03/24/2016] [Accepted: 03/24/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND The impact of intravenous (IV) beta-blockers before primary percutaneous coronary intervention (PPCI) on infarct size and clinical outcomes is not well established. OBJECTIVES This study sought to conduct the first double-blind, placebo-controlled international multicenter study testing the effect of early IV beta-blockers before PPCI in a general ST-segment elevation myocardial infarction (STEMI) population. METHODS STEMI patients presenting <12 h from symptom onset in Killip class I to II without atrioventricular block were randomized 1:1 to IV metoprolol (2 × 5-mg bolus) or matched placebo before PPCI. Primary endpoint was myocardial infarct size as assessed by cardiac magnetic resonance imaging (CMR) at 30 days. Secondary endpoints were enzymatic infarct size and incidence of ventricular arrhythmias. Safety endpoints included symptomatic bradycardia, symptomatic hypotension, and cardiogenic shock. RESULTS A total of 683 patients (mean age 62 ± 12 years; 75% male) were randomized to metoprolol (n = 336) or placebo (n = 346). CMR was performed in 342 patients (54.8%). Infarct size (percent of left ventricle [LV]) by CMR did not differ between the metoprolol (15.3 ± 11.0%) and placebo groups (14.9 ± 11.5%; p = 0.616). Peak and area under the creatine kinase curve did not differ between both groups. LV ejection fraction by CMR was 51.0 ± 10.9% in the metoprolol group and 51.6 ± 10.8% in the placebo group (p = 0.68). The incidence of malignant arrhythmias was 3.6% in the metoprolol group versus 6.9% in placebo (p = 0.050). The incidence of adverse events was not different between groups. CONCLUSIONS In a nonrestricted STEMI population, early intravenous metoprolol before PPCI was not associated with a reduction in infarct size. Metoprolol reduced the incidence of malignant arrhythmias in the acute phase and was not associated with an increase in adverse events. (Early-Beta blocker Administration before reperfusion primary PCI in patients with ST-elevation Myocardial Infarction [EARLY-BAMI]; EudraCT no: 2010-023394-19).
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Affiliation(s)
- Vincent Roolvink
- Department of Cardiology, Isala Hospital, Zwolle, the Netherlands
| | - Borja Ibáñez
- Department of Cardiology, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Department of Cardiology, IIS-Fundacion Jimenez Díaz Hospital, Madrid, Spain
| | | | - Gonzalo Pizarro
- Department of Cardiology, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Department of Cardiology, Hospital Universitario Quirón, Universidad Europea de Madrid & Hospital Ruber-Quirónsalud, Madrid, Spain
| | - Niels van Royen
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Alonso Mateos
- Department of Cardiology, Servicio de Urgencia Medica de Madrid (SUMMA 112), Madrid, Spain
| | | | - Noemi Escalera
- Department of Cardiology, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | - Erik Lipsic
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Agustín Albarran
- Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital 12 de Octubre, Madrid, Spain
| | - Antonio Fernández-Ortiz
- Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital Clínico San Carlos, Madrid, Spain
| | - Francisco Fernández-Avilés
- Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital Gregorio Marañón, Madrid, Spain
| | - Javier Goicolea
- Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital Puerta de Hierro, Madrid, Spain
| | - Javier Botas
- Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital Fundación Alcorcón, Madrid, Spain
| | - Wouter Remkes
- Department of Cardiology, Isala Hospital, Zwolle, the Netherlands
| | | | - Elvin Kedhi
- Department of Cardiology, Isala Hospital, Zwolle, the Netherlands
| | - José L Zamorano
- Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital Ramón y Cajal, Madrid, Spain
| | - Felipe Navarro
- Department of Cardiology, IIS-Fundacion Jimenez Díaz Hospital, Madrid, Spain; Department of Cardiology, Codigo Infarto, Madrid, Spain
| | - Fernando Alfonso
- Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital de La Princesa, Madrid, Spain
| | - Alberto García-Lledó
- Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Joaquin Alonso
- Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital de Getafe, Madrid, Spain
| | - Maarten van Leeuwen
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Robin Nijveldt
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Sonja Postma
- Diagram, Diagnostic Research and Management, Zwolle, the Netherlands
| | - Evelien Kolkman
- Diagram, Diagnostic Research and Management, Zwolle, the Netherlands
| | - Marcel Gosselink
- Department of Cardiology, Isala Hospital, Zwolle, the Netherlands
| | - Bart de Smet
- Department of Cardiology, Meander Medisch Centrum, Amersfoort, the Netherlands
| | - Saman Rasoul
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Jan J Piek
- Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Valentin Fuster
- Department of Cardiology, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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Arcari L, Cimino S, De Luca L, Francone M, Galea N, Reali M, Carbone I, Iacoboni C, Agati L. Impact of Heart Rate on Myocardial Salvage in Timely Reperfused Patients with ST-Segment Elevation Myocardial Infarction: New Insights from Cardiovascular Magnetic Resonance. PLoS One 2015; 10:e0145495. [PMID: 26716452 PMCID: PMC4696663 DOI: 10.1371/journal.pone.0145495] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 12/04/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Previous studies evaluating the progression of the necrotic wave in relation to heart rate were carried out only in animal models of ST-elevated myocardial infarction (STEMI). Aim of the study was to investigate changes of myocardial salvage in relation to different heart rates at hospital admission in timely reperfused patients with STEMI by using cardiovascular magnetic resonance (CMR). METHODS One hundred-eighty-seven patients with STEMI successfully and timely treated with primary coronary angioplasty underwent CMR five days after hospital admission. According to the heart rate at presentation, patients were subcategorized into 5 quintiles: <55 bpm (group I, n = 44), 55-64 bpm (group II, n = 35), 65-74 bpm (group III, n = 35), 75-84 bpm (group IV, n = 37), ≥85 bpm (group V, n = 36). Area at risk, infarct size, microvascular obstruction (MVO) and myocardium salvaged index (MSI) were assessed by CMR using standard sequences. RESULTS Lower heart rates at presentation were associated with a bigger amount of myocardial salvage after reperfusion. MSI progressively decreased as the heart rates increased (0.54 group I, 0.46 group II, 0.38 group III, 0.34 group IV, 0.32 group V, p<0.001). Stepwise multivariable analysis showed heart rate, peak troponin and the presence of MVO were independent predictor of myocardial salvage. No changes related to heart rate were observed in relation to area at risk and infarct size. CONCLUSIONS High heart rates registered before performing coronary angioplasty in timely reperfused patients with STEMI are associated with a reduction in salvaged myocardium. In particular, salvaged myocardium significantly reduced when heart rate at presentation is ≥85 bpm.
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Affiliation(s)
- Luca Arcari
- Department of Cardiology, Sapienza University of Rome, Rome, Italy
| | - Sara Cimino
- Department of Cardiology, Sapienza University of Rome, Rome, Italy
| | - Laura De Luca
- Department of Cardiology, Sapienza University of Rome, Rome, Italy
| | - Marco Francone
- Department of Radiology, Sapienza University of Rome, Rome Italy
| | - Nicola Galea
- Department of Radiology, Sapienza University of Rome, Rome Italy
| | - Manuela Reali
- Department of Cardiology, Sapienza University of Rome, Rome, Italy
| | - Iacopo Carbone
- Department of Radiology, Sapienza University of Rome, Rome Italy
| | - Carlo Iacoboni
- Department of Cardiology, Sapienza University of Rome, Rome, Italy
| | - Luciano Agati
- Department of Cardiology, Sapienza University of Rome, Rome, Italy
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19
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Roolvink V, Rasoul S, Ottervanger JP, Dambrink JHE, Lipsic E, van der Horst ICC, de Smet B, Kedhi E, Marcel Gosselink AT, Piek JJ, Sanchez-Brunete V, Ibanez B, Fuster V, Van't Hof AWJ. Rationale and design of a double-blind, multicenter, randomized, placebo-controlled clinical trial of early administration of intravenous β-blockers in patients with ST-elevation myocardial infarction before primary percutaneous coronary intervention: EARLY β-blocker administration before primary PCI in patients with ST-elevation myocardial infarction trial. Am Heart J 2014; 168:661-6. [PMID: 25440793 DOI: 10.1016/j.ahj.2014.07.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 07/11/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND β-Blockers have a class 1a recommendation in the treatment of patients with ST-elevation myocardial infarctions (STEMIs), as they are associated with a reduced mortality, recurrent myocardial infarction, life-threatening arrhythmias, and with prevention of unfavorable left ventricular remodeling. Whether early administration before primary percutaneous coronary intervention (PCI) of intravenous β-blockers reduces the infarct size in the current era is unknown. HYPOTHESIS We postulate that the early administration of β-blockers will reduce the myocardial infarcted area as assessed by magnetic resonance imaging (MRI) at 30 days. DESIGN In a multinational, multicenter, double-blind, placebo-controlled, randomized trial, patients with symptoms and signs of STEMI and transferred to a hospital for primary PCI will be randomized in a 1:1 fashion to intravenous metoprolol (5 mg twice daily) administration or placebo. Before admission, study treatment will be started as soon as possible after the diagnosis of STEMI. After admission, primary PCI will be performed as per standard of care. After primary PCI, medical treatment will occur as per current guidelines in all patients, including the use of oral β-blockers. The primary end point is the myocardial infarct size as assessed by MRI at 30 days. Based on a superiority design and assuming an 18% relative infarct size reduction (from 28% to 23.5%), 408 patients are required to be enrolled, accounting for 20% drop-out (α = .05 and power = 80%). SUMMARY The EARLY-BAMI trial is a multinational, multicenter, double-blind, placebo-controlled, randomized clinical trial that will investigate the impact of intravenous metoprolol administration before primary PCI for STEMI on myocardial infarct size as measured with MRI at 30 days.
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Affiliation(s)
- Vincent Roolvink
- Isala Klinieken, Department of Cardiology, Zwolle, The Netherlands.
| | - Saman Rasoul
- Isala Klinieken, Department of Cardiology, Zwolle, The Netherlands
| | | | | | - Erik Lipsic
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
| | - Iwan C C van der Horst
- University of Groningen, University Medical Center Groningen, Department of Critical Care, Groningen, The Netherlands
| | - Bart de Smet
- Meander Medisch Centrum, Department of Cardiology, Amersfoort, The Netherlands
| | - Elvin Kedhi
- Isala Klinieken, Department of Cardiology, Zwolle, The Netherlands
| | | | - Jan J Piek
- Academic Medical Center, Department of Cardiology, Amersfoort, The Netherlands
| | | | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Spain
| | - Valentin Fuster
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Spain; The Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, NY
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Valle JA, Zhang M, Dixon S, Aronow HD, Share D, Naoum JB, Gurm HS. Impact of pre-procedural beta blockade on inpatient mortality in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction. Am J Cardiol 2013; 111:1714-20. [PMID: 23528025 DOI: 10.1016/j.amjcard.2013.02.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 02/17/2013] [Accepted: 02/17/2013] [Indexed: 12/25/2022]
Abstract
Early use of β blockers (BBs) in acute myocardial infarction remains controversial, with some studies demonstrating benefit and others harm. The aim of this study was to assess the association between pre-percutaneous coronary intervention (PCI) BB use and in-hospital outcomes in patients who underwent primary PCI for ST-segment elevation myocardial infarction between 2007 and 2009 at institutions participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC-2). Inverse propensity score weighting was used to account for the nonrandomized use of pre-PCI BBs. The cohort comprised 7,667 patients, with 4,769 (62%) receiving pre-PCI BBs. These patients were older, with higher rates of diabetes mellitus, hypertension, and previous myocardial infarction, PCI, or coronary artery bypass grafting. In adjusted models, pre-PCI BB use was associated with lower rates of intraprocedural ventricular tachycardia or ventricular fibrillation (odds ratio [OR] 0.58, p <0.01) and lower in-hospital mortality (OR 0.65, p = 0.022), with increases in rates of emergent coronary artery bypass grafting (OR 1.56, p <0.01) and repeat PCI (OR 1.93, p <0.01). There were no significant increases in rates of cardiogenic shock and congestive heart failure. In conclusion, pre-PCI BB use in this population was associated with decreased arrhythmia and mortality, without increasing rates of cardiogenic shock and heart failure but with higher rates of repeat PCI and emergent coronary artery bypass grafting, suggesting that there may yet remain a role for early BB use in pre-PCI patients with ST-segment elevation myocardial infarctions.
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Affiliation(s)
- Javier A Valle
- Division of Cardiology, University of Colorado School of Medicine, Denver, CO, USA
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21
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22
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Park H, Otani H, Noda T, Sato D, Okazaki T, Ueyama T, Iwasaka J, Yamamoto Y, Iwasaka T. Intracoronary followed by intravenous administration of the short-acting β-blocker landiolol prevents myocardial injury in the face of elective percutaneous coronary intervention. Int J Cardiol 2012; 167:1547-51. [PMID: 22608892 DOI: 10.1016/j.ijcard.2012.04.096] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 01/27/2012] [Accepted: 04/14/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Myocardial injury during elective percutaneous coronary intervention (PCI) is associated with higher subsequent cardiac events and mortality. β-Blockers have been used to reduce myocardial injury during ischemia and reperfusion. We investigated whether intracoronary followed by intravenous administration of the short-acting β-blocker landiolol prevents myocardial injury in the face of elective PCI. METHODS AND RESULTS Patients undergoing elective PCI (n=70) were randomly assigned to the landiolol (n=35) or control (n=35) group. Landiolol or saline was administered into target vessels through a balloon catheter for 1min before and after first balloon inflation followed by continuous intravenous administration for 6h after PCI. The incidence of myocardial injury defined by cardiac troponin-I (cTnI) >/=0.05 ng/ml was 79% of the patients in the control group compared to 56% in the landiolol group (p=0.04). The cTnI level at 24h after PCI tended to be lower in the landiolol group (0.57 ± 1.14 versus 1.27 ± 2.48 ng/ml; p=0.07), while the CK-MB level was not significantly different between the landiolol and control groups. The incidence of peri-procedural myocardial infarction defined by cTnI >/=0.12 ng/ml was significantly (p=0.02) lower in the landiolol group (41%) compared to the control group (70%). There was no incidence of coronary spasm, hypotension, bradycardia or heart failure during and after PCI in the two groups. CONCLUSIONS Brief intracoronary followed by continuous intravenous administration of landiolol is safe and effective for myocardial protection in the face of elective PCI.
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Affiliation(s)
- Haengnam Park
- Second Department of Internal Medicine, Kansai Medical University, Moriguchi City, Japan
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23
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Hanada K, Higuma T, Nishizaki F, Sukekawa T, Yokota T, Yamada M, Saito S, Kushibiki M, Oikawa K, Abe N, Tomita H, Osanai T, Okumura K. Randomized Study on the Efficacy and Safety of Landiolol, an Ultra-Short-Acting .BETA.1-Adrenergic Blocker, in Patients With Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Circ J 2012; 76:439-45. [DOI: 10.1253/circj.cj-11-0947] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kenji Hanada
- Department of Cardiology, Hirosaki University Graduate School of Medicine
| | - Takumi Higuma
- Department of Cardiology, Hirosaki University Graduate School of Medicine
| | - Fumie Nishizaki
- Department of Cardiology, Hirosaki University Graduate School of Medicine
| | - Takanori Sukekawa
- Department of Cardiology, Hirosaki University Graduate School of Medicine
| | - Takashi Yokota
- Department of Cardiology, Hirosaki University Graduate School of Medicine
| | - Masahiro Yamada
- Department of Cardiology, Hirosaki University Graduate School of Medicine
| | - Shin Saito
- Department of Cardiology, Hirosaki University Graduate School of Medicine
| | - Motoi Kushibiki
- Department of Cardiology, Hirosaki University Graduate School of Medicine
| | - Koichi Oikawa
- Department of Cardiology, Hirosaki University Graduate School of Medicine
| | - Naoki Abe
- Department of Cardiology, Hirosaki University Graduate School of Medicine
| | - Hirofumi Tomita
- Department of Cardiology, Hirosaki University Graduate School of Medicine
| | - Tomohiro Osanai
- Department of Cardiology, Hirosaki University Graduate School of Medicine
| | - Ken Okumura
- Department of Cardiology, Hirosaki University Graduate School of Medicine
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24
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Raedschelders K, Ansley DM, Chen DDY. The cellular and molecular origin of reactive oxygen species generation during myocardial ischemia and reperfusion. Pharmacol Ther 2011; 133:230-55. [PMID: 22138603 DOI: 10.1016/j.pharmthera.2011.11.004] [Citation(s) in RCA: 276] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 11/04/2011] [Indexed: 02/07/2023]
Abstract
Myocardial ischemia-reperfusion injury is an important cause of impaired heart function in the early postoperative period subsequent to cardiac surgery. Reactive oxygen species (ROS) generation increases during both ischemia and reperfusion and it plays a central role in the pathophysiology of intraoperative myocardial injury. Unfortunately, the cellular source of these ROS during ischemia and reperfusion is often poorly defined. Similarly, individual ROS members tend to be grouped together as free radicals with a uniform reactivity towards biomolecules and with deleterious effects collectively ascribed under the vague umbrella of oxidative stress. This review aims to clarify the identity, origin, and progression of ROS during myocardial ischemia and reperfusion. Additionally, this review aims to describe the biochemical reactions and cellular processes that are initiated by specific ROS that work in concert to ultimately yield the clinical manifestations of myocardial ischemia-reperfusion. Lastly, this review provides an overview of several key cardioprotective strategies that target myocardial ischemia-reperfusion injury from the perspective of ROS generation. This overview is illustrated with example clinical studies that have attempted to translate these strategies to reduce the severity of ischemia-reperfusion injury during coronary artery bypass grafting surgery.
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Affiliation(s)
- Koen Raedschelders
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine. The University of British Columbia, Vancouver, BC, Canada.
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25
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Park H, Otani H, Oishi C, Fujikawa M, Yamashita K, Okazaki T, Sato D, Ueyama T, Iwasaka J, Yamamoto Y, Iwasaka T. Efficacy of intracoronary administration of a short-acting β-blocker landiolol during reperfusion in pigs. Int J Cardiol 2011; 146:347-53. [DOI: 10.1016/j.ijcard.2009.07.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Revised: 06/23/2009] [Accepted: 07/19/2009] [Indexed: 11/29/2022]
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26
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Lethal myocardial reperfusion injury: a necessary evil? Int J Cardiol 2010; 151:3-11. [PMID: 21093938 DOI: 10.1016/j.ijcard.2010.10.056] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 10/23/2010] [Accepted: 10/27/2010] [Indexed: 12/11/2022]
Abstract
Despite being the most effective means of limiting infarct size, coronary reperfusion comes at a price and induces additional damage to the myocardium. Lethal reperfusion injury (death of myocytes that were viable at the time of reperfusion) is an increasingly acknowledged phenomenon. There are many interconnected mechanisms involved in this type of cell death. Calcium overload (generating myocyte hypercontracture), rapid recovery of physiological pH, neutrophil infiltration of the ischemic area, opening of the mitochondrial permeability-transition-pore (PTP), and apoptotic cell death are among the more important mechanisms involved in reperfusion injury. The activation of a group of proteins called reperfusion injury salvage kinases (RISK) pathway confers protection against reperfusion injury, mainly by inhibiting the opening of the mitochondrial PTP. Many interventions have been tested in human trials triggered by encouraging animal studies. In the present review we will explain in detail the main mechanism involved in reperfusion injury, as well as the various approaches (pre-clinical and human trials) performed targeting these mechanisms. Currently, no intervention has been consistently shown to reduce reperfusion injury in large randomized multicenter trials, but the research in this field is intense and the future is highly promising.
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27
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Kloner RA, Rezkalla SH. Cardiac protection during acute myocardial infarction: Where do we stand in 2004? J Am Coll Cardiol 2004; 44:276-86. [PMID: 15261919 DOI: 10.1016/j.jacc.2004.03.068] [Citation(s) in RCA: 146] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2004] [Revised: 03/23/2004] [Accepted: 03/31/2004] [Indexed: 12/21/2022]
Abstract
Despite better outcomes with early coronary artery reperfusion for the treatment of acute ST-elevation myocardial infarction (MI), morbidity and mortality from acute myocardial infarction (AMI) remain significant, the incidence of congestive heart failure continues to increase, and there is a need to provide better cardioprotection (therapy that reduces the amount of necrosis that may be coupled with better clinical outcome) in the setting of AMI. Since the introduction of the concept of cardiac protection over a quarter of a century ago, various interventions have been investigated to reduce myocardial infarct size. Intravenous beta-blockers administered in the early hours of infarction were clearly shown to be of benefit. Intravenous adenosine appeared promising for anterior wall AMIs, as did cariporide in some studies. Glucose-insulin-potassium infusion was beneficial in certain subgroups of patients, particularly diabetics. A variety of other medications were studied with negative or marginal results. The best strategy to limit infarct size is early reperfusion with percutaneous coronary stenting or thrombolytic therapy. Stenting is superior and should be adopted whenever there is a qualified laboratory available. Available resources should focus on decreasing time from onset of symptoms to start of reperfusion and maintaining vessel patency. Future studies powered to better assess clinical outcome are needed for adjunctive therapy with adenosine, K(ATP) channel openers, Na(+)/H(+) exchange inhibitors, and hypothermia.
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Affiliation(s)
- Robert A Kloner
- Heart Institute, Good Samaritan Hospital, Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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28
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Field JM. The reperfusion era. Strategies for establishing or maintaining coronary patency. Cardiol Clin 2002; 20:137-57, ix. [PMID: 11845541 DOI: 10.1016/s0733-8651(03)00070-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Only 3 decades ago, controversy existed over the origin of the thrombus that occluded coronary arteries during myocardial infarction (MI). Then, the acute clinical angiographic studies of DeWood butterssed new pathological and experimental evidence that the thrombus was the proximate cause of MI and unstable angina. The remaining years of the 20th century saw an explosion of knowledge delineating a spectrum of related disorders now collectively called acute coronary syndromes (ACS). The clinician managing patients is confronted with an array of evidence as more than 75,000 patients worldwide have been randomized to clinical trials in ACS. This article reviews key pathophysiological concepts, presents an initial strategy for triage of patients, and summarizes evidence-based medicine guiding therapy for acute coronary lesions.
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Affiliation(s)
- John M Field
- Division of Cardiology, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
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29
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Kern KB, Hilwig RW, Warner A, Basnight M, Ewy GA. Failure of intravenous metoprolol to limit acute myocardial infarct size in a nonreperfused porcine model. Am Heart J 1995; 129:650-5. [PMID: 7900612 DOI: 10.1016/0002-8703(95)90310-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The usefulness of intravenous beta-adrenergic receptor blockade in limiting infarct size when neither reperfusion nor collateral flow occurs is unknown. The effect of intravenous metoprolol on limiting myocardial infarct size was therefore examined in a nonreperfused porcine model. Closed-chest techniques were used to occlude the left anterior descending coronary artery, after which animals were randomized at 20 minutes to receive intravenous metoprolol, 0.75 mg/kg, or placebo. Infarct size examined at 5 hours with Evans blue and triphenyltetrazolium staining techniques was expressed as a percentage of total ventricular myocardium at ischemic risk. This percentage was not significantly different between the groups (84% +/- 5% with metoprolol vs 90% +/- 4% with placebo; p = 0.4). Myocardial infarct size was not significantly decreased at 5 hours by early administration of intravenous metoprolol when the infarct artery remained occluded and collateral flow was minimal.
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Affiliation(s)
- K B Kern
- Department of Medicine, University of Arizona College of Medicine, Tucson
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30
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Drake-Holland AJ, Belcher PR, Hynd J, Noble MI. Infarct size in rabbits: a modified method illustrated by the effects of propranolol and trimetazidine. Basic Res Cardiol 1993; 88:250-8. [PMID: 8216176 DOI: 10.1007/bf00794997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Following a 45-min period of coronary occlusion the myocardial infarct that developed after 24 h of blood reperfusion in the rabbit heart was studied in three groups of animals: controls (n = 7), and those pretreated with 3 mg.kg-1 of the piperazine derivative, trimetazidine (n = 7) or propranolol at 0.3 mg.kg-1 (n = 6). Twenty-four hours after coronary artery ligation for 45 min infarct size was measured in myocardial slices using trinitrophenyl-tetrazolium staining, and the "area at risk" was determined by injection of zinc/cadmium particles and delineated by imaging under fluorescent light the areas of tissue that did not fluoresce. The range of "area at risk" was similar in all of the groups. There was a significant reduction in the size of infarct that developed in the trimetazidine treated group when compared with the controls. In the propranolol treated group there was a slight reduction in infarct size when compared to control, but this was less than in the trimetazidine treated group and did not reach statistical significance. It is concluded that pretreatment with trimetazidine in the blood perfused rabbit heart is effective in reducing myocardial infarct size.
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Affiliation(s)
- A J Drake-Holland
- Academic Unit of Cardiovascular Medicine, Charing Cross & Westminster Medical School, London, UK
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31
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Nasa Y, Hoque AN, Ichihara K, Abiko Y. Cardioprotective effect of pindolol in ischemic-reperfused isolated rat hearts. Eur J Pharmacol 1992; 213:171-81. [PMID: 1521558 DOI: 10.1016/0014-2999(92)90678-w] [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: 12/27/2022]
Abstract
The effects of pindolol and timolol on ischemia reperfusion damage were studied in isolated working rat hearts. Ischemia (15 min) decreased the mechanical function and the energy state, and increased the tissue levels of free fatty acids (FFA). During reperfusion (20 min), the mechanical function did not recover, but the energy state recovered incompletely, whereas FFA increased further. Pindolol (50 microM) accelerated recovery of the mechanical function and the energy state that had been decreased by ischemia during reperfusion, and inhibited the accumulation of FFA during ischemia and reperfusion, especially when it was applied during the whole period of reperfusion. Timolol (50 microM), however, did not accelerate recovery of the mechanical function and the energy state during reperfusion, although it attenuated FFA accumulation during reperfusion. The pindolol-induced recovery of the mechanical function during reperfusion was reduced by timolol. The results suggest that the intrinsic sympathomimetic activity of pindolol may play an important role, at least in part, in producing the cardioprotective effect, especially during reperfusion.
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Affiliation(s)
- Y Nasa
- Department of Pharmacology, Asahikawa Medical College, Japan
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32
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Abstract
To achieve a better understanding of the major factors that determine infarct size in non-human primates, a mathematical model was constructed using stepwise regression analysis. The model was developed on the basis of infarct size measurements, including the anatomical area at risk, regional myocardial blood flow measurements and hemodynamic determinants obtained in 23 control baboons undergoing up to 2 h of coronary artery thrombosis followed by thrombolysis. In this model, the size of the perfusion bed of the occluded coronary artery and the duration of coronary artery occlusion were found to be the only important predictors of infarct size (expressed as a percentage of left ventricular mass). R2 (square or the multiple correlation coefficient) was 70% in this model. Collateral blood flow and rate-pressure product were not identified as important predictors of infarct size. In a second group of eight baboons, atenolol (0.1 mg.kg-1) was administered intravenously 15 min after the onset of coronary artery thrombosis. Predicted infarct size (based on the mathematical model obtained in the control group) was larger than the observed infarct size in seven out of eight cases. In four instances observed infarct size was smaller than the 95% lower limit of the predicted value. It is concluded that the determinants of infarct size in non-human primates differ from those in canine models with respect to collateral flow and estimates of myocardial oxygen consumption (rate pressure product). The developed mathematical model of infarct size prediction allows the detection of cardioprotective drug effects with an acceptable efficacy.
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Affiliation(s)
- W Flameng
- Department of Experimental Cardiac Surgery, Catholic University Leuven, Belgium
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33
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Kavanaugh KM, Aisen AM, Fechner KP, Chenevert TL, Buda AJ. The effects of propranolol on regional cardiac metabolism during ischemia and reperfusion assessed by magnetic resonance spectroscopy. Am Heart J 1990; 119:1274-9. [PMID: 2353614 DOI: 10.1016/s0002-8703(05)80175-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sixteen anesthetized New Zealand white rabbits were subjected to thoracotomy, and a reversible snare occluder was attached around a large branch of the left circumflex coronary artery. A 1.3 cm. diameter nuclear magnetic resonance (NMR) surface coil was placed adjacent to the myocardium perfused by this vessel. The animals were divided into two groups of eight animals each, treatment and control. The rabbits were studied using a 2.0 T magnetic resonance (MR) spectrometer, and baseline spectra were acquired. The treatment animals then received intravenous propranolol (1.5 mg/kg) and the control animals received an equal volume of saline. Spectra were then acquired during a 20-minute occlusion period and during subsequent reperfusion. Animals in both groups showed expected decreases in phosphocreatine and adenosine triphosphate and an increase in inorganic phosphate during occlusion; these changes reverted toward baseline values with reperfusion. There were no significant differences between the two groups. The myocardium became acidotic during occlusion in both groups, but significantly more so in the control animals: during the first 10 minutes of occlusion pH was 7.30 +/- 0.41 in the treatment group versus 6.55 +/- 0.24 for controls (p = 0.0005). During the second 10 minutes of occlusion pH was 7.05 +/- 0.65 in the treatment group versus 6.24 +/- 0.25 in controls (p = 0.0053). We conclude that attenuation of intracellular acidosis by propranolol during myocardial ischemia was evident by MR spectroscopy in this animal model.
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Affiliation(s)
- K M Kavanaugh
- Department of Internal Medicine, University of Michigan Medical School
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34
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The effect of propranolol on the cerebral electrical response to deep hypothermia and total circulatory arrest in lambs. J Thorac Cardiovasc Surg 1990. [DOI: 10.1016/s0022-5223(20)31459-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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35
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Wappel M, Zalewski A, Savage M, Hessen S, Goldberg S, Maroko PR. Myocardial salvage after regional beta-adrenergic blockade. Am Heart J 1989; 117:37-42. [PMID: 2911988 DOI: 10.1016/0002-8703(89)90654-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
UNLABELLED The aim of the study was to determine whether regional beta-adrenergic blockade via the coronary sinus limited myocardial damage after coronary artery occlusion in the canine model. Accordingly, open-chest anesthetized dogs were randomly allocated to one of three groups: a control group and groups treated with propranolol (in doses of 0.02, 0.2, and 2.0 mg/kg) given either intravenously or via the coronary sinus. The hypoperfused zone (i.e., risk area) and the extent of myocardial damage were assessed by autoradiography and triphenyltetrazolium chloride staining, respectively. Myocardial damage expressed as a percent of the hypoperfused zone was 84 +/- 5% in the control group (n = 9) and 78 +/- 7% (0.02 mg/kg, n = 7, NS), 63 +/- 6% (0.2 mg/kg, n = 7, p less than 0.05), and 62 +/- 7% (2.0 mg/kg, n = 9, p less than 0.02) in the groups receiving intravenous propranolol and 73 +/- 6% (0.02 mg/kg, n = 7, NS), 58 +/- 7% (0.2 mg/kg, n = 7, p less than 0.01), and 44 +/- 9% (2.0 mg/kg, n = 9, p less than 0.001) in groups receiving propranolol via the cardiac veins. There was a significant enhancement of myocardial salvage with increasing doses of propranolol delivered via the cardiac veins (linear regression trend, p less than 0.05). In contrast, myocardial damage expressed as a percent of the hypoperfused zone remained comparable with propranolol doses of 0.2 and 2.0 mg/kg administered intravenously (linear regression trend, NS). IN CONCLUSION (1) regional beta-adrenergic blockade via the cardiac veins afforded significant myocardial salvage and (2) the regional administration of propranolol resulted in significant reduction of myocardial damage in a dose-dependent fashion.
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Affiliation(s)
- M Wappel
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA 19107
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Brush JE, Brand DA, Acampora D, Goldman L, Cabin HS. Relation of peak creatine kinase levels during acute myocardial infarction to presence or absence of previous manifestations of myocardial ischemia (angina pectoris or healed myocardial infarction). Am J Cardiol 1988; 62:534-7. [PMID: 3414544 DOI: 10.1016/0002-9149(88)90650-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The hypothesis that acute myocardial infarction (MI) is more extensive in patients without previous angina or healed MI was evaluated in 177 patients with documented recent acute MI. Ninety-nine patients (56%) had no previous angina or healed MI (negative history group), and the remaining 78 patients (44%) had a previous history of angina or healed MI (positive history group). The mean peak creatine kinase (CK) level in the negative history group was 784 compared with 419 IU in the positive history group (p less than 0.0001). The mean peak CK-MB level in the negative history group was 128 compared with 76 IU in the positive history group (p less than 0.001). The mean peak CK-MB level was higher in the negative history group after controlling for age, streptokinase administration, previous coronary artery bypass grafting or treatment with beta-blocking agents. Despite the high frequency of healed MI in the positive history group (73%), the rates of in-hospital complications were similar for the 2 groups. Patients with acute MI without previous angina or healed MI have substantially higher peak CK and CK-MB levels; this implies a larger MI than in patients with previous angina or healed MI.
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Affiliation(s)
- J E Brush
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
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37
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Euler DE, Hughes PJ, Scanlon PJ. Comparison of the effects of acute and chronic beta-blockade on infarct size in the dog after circumflex occlusion. Cardiovasc Drugs Ther 1988; 2:231-8. [PMID: 2908721 DOI: 10.1007/bf00051239] [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: 01/03/2023]
Abstract
In order to compare the effects of acute and chronic beta-blockade on infact size, the left circumflex coronary artery was occluded for 6 hours in 33 anesthetized dogs. The dogs (18 to 22 kg) were divided into three groups; group 1 (N = 10) served as controls, group 2 received intravenous nadolol (average dose 1.25 mg/kg) just prior to coronary occlusion, and group 3 received oral nadolol (80 mg) twice daily for 16 days prior to coronary occlusion. To ensure equivalent degrees of beta-blockade at the time of occlusion, group 2 and 3 dogs were given incremental doses of intravenous nadolol to abolish the chronotropic response to isoproterenol (2 mu/kg IV). Left ventricular pressure, its first derivative (dP/dt), and heart rate were monitored. The anatomic risk region was determined antemortem by Evan's blue staining while the infarct zone was delineated postmortem by tetrazolium staining. Compared to Group 1, heart rate was 22% lower in group 2 and 15% lower in group 3 dogs 6 hours after occlusion (p less than 0.05). There were no differences among groups in peak left ventricular systolic pressure or mean arterial pressure. Infarct size as a function of the area at risk was 68 +/- 3% in group 1, 52 +/- 7% in group 2, and 44 +/- 8% in group 3. A significant difference was found only between groups 3 and 1. The data suggest that chronic beta-blockade provides greater protection against ischemic-induced necrosis than does acute beta-blockade. The greater protective effect of chronic beta-blockade may be due to chronic adaptive changes in either blood flow or metabolism.
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Affiliation(s)
- D E Euler
- Department of Physiology, Loyola University Medical Center, Maywood, Illinois 60153
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Greve G, Rotevatn S, Berstad K, Jodalen H, Grong K, Stangeland L. Effects of verapamil and timolol on cellular morphometric changes in cat hearts with regional ischaemia. VIRCHOWS ARCHIV. A, PATHOLOGICAL ANATOMY AND HISTOPATHOLOGY 1988; 412:291-9. [PMID: 3125669 DOI: 10.1007/bf00750254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In twenty-one anaesthetized open chest cats the left anterior descending coronary artery (LAD) was occluded for three hours. Seven cats were pretreated with a bolus injection of Verapamil, followed by a continuous infusion of Verapamil during the ischaemic period. Seven cats were pretreated with a bolus injection of Timolol to a heart rate reduction of 20 beats/min or more and seven cats were given saline. In the latter two groups the cats received a continuous infusion of saline during the period of coronary occlusion. Biopsies were taken from the mid-myocardium of the normal, border and ischaemic zones, as defined by fluorescein staining, and verified by blood flow measurements with radiolabelled microspheres. Standard point counting techniques were used for calculations of fractional volumes of mitochondria, cytoplasm and myofibrils as well as of mitochondrial surface density and surface to volume ratio. We observed a cytoplasmic oedema in the border and ischaemic zones, that was not altered by medical treatment. In the border zone of the control cats there is greater mitochondrial swelling than in the ischaemic zone. This particular swelling is not seen in the treatment groups. However, in the normal and border zones of the verapamil group the mitochondria are smaller when compared with the respective zones in the two other groups, but increases relatively more in size in the border and ischaemic zones. Furthermore, we measured the water content, sarcomere length and per cent heavily damaged cells. These variables were not altered by Verapamil or Timolol in any zone when compared with the respective zones in the control group.
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Affiliation(s)
- G Greve
- Department of Anatomy, University of Bergen, Norway
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Vassanelli C, Menegatti G, Nidasio GP, Franceschini L, Cocco C, Rizzotti P. Comparison of different pharmacological interventions on enzymatic parameters during acute myocardial infarction. Clin Biochem 1987; 20:441-7. [PMID: 3124977 DOI: 10.1016/0009-9120(87)90012-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The concept that acute myocardial infarction is a dynamic event and that different interventions can modify the extent of the necrosis, has led to renewed interest in early pharmacological and surgical treatments designed to reduce the ischemic injury. To evaluate the effects of different pharmacological interventions aimed to reduce the extent of necrosis, we studied 166 patients (138 male and 28 female, mean age of 59.4 +/- 11.3 years) admitted within 6 h after chest pain and treated with a single therapy during the first 72 h. Enzymatic infarct size (IS) was calculated by serial creatine kinase isoenzyme MB determinations using a compartmental model. Six groups of patients were evaluated: 33 patients were treated only with antiplatelet drugs, 38 with anticoagulants, 34 with intravenous thrombolytic therapy, 20 with calcium channel blockers, 25 with nitrates, and 16 with beta-blockers. Estimated IS (gEq/m2) and elimination constant (Kd, U/L/h) did not differ in the six groups, but patients treated with streptokinase had higher release constant (Ka, U/L/h) and shorter time to peak CK-MB value. Early treatment (less than or equal to 2 h after chest pain) had a favourable effect on the enzymatic IS only in patients treated with calcium channel blockers (p less than 0.005).
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Affiliation(s)
- C Vassanelli
- Dipartimento di Cardiologia, Universita di Verona, Italia
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Maza SR, Frishman WH. Therapeutic options to minimize free radical damage and thrombogenicity in ischemic/reperfused myocardium. Am Heart J 1987; 114:1206-15. [PMID: 3314441 DOI: 10.1016/0002-8703(87)90198-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- S R Maza
- Department of Medicine, Einstein College of Medicine, Bronx, N.Y
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41
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Van de Werf F, Vanhaecke J, Jang IK, Flameng W, Collen D, De Geest H. Reduction in infarct size and enhanced recovery of systolic function after coronary thrombolysis with tissue-type plasminogen activator combined with beta-adrenergic blockade with metoprolol. Circulation 1987; 75:830-6. [PMID: 3103951 DOI: 10.1161/01.cir.75.4.830] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The effect of beta-adrenergic blockade on the salvage and functional recovery of reperfused myocardium was investigated in anesthetized dogs. Immediately after thrombotic occlusion of the left anterior descending coronary artery, the cardioselective beta-blocking agent metoprolol was given intravenously at a dose of 0.5 mg/kg infused over 10 min. One hour after the onset of occlusion, recanalization was initiated by intravenous infusion of recombinant human tissue-type plasminogen activator (rt-PA, 10 micrograms/kg/min for 30 min). Anatomic infarct size expressed as percent of the left ventricular mass (I/LV), global ejection fraction, and mean systolic shortening of the segmental radii (SS) of the infarcted area were measured either after 24 hr or 1 week in six groups of six dogs each: group I (rt-PA + metoprolol, evaluated at 24 hr), group II (rt-PA + metoprolol, evaluated at 1 week, group III (rt-PA alone, evaluated at 24 hr), group IV (rt-PA alone, evaluated at 1 week), group V (persistent occlusion, evaluated at 24 hr), and group VI (persistent occlusion, evaluated at 1 week). The smallest infarcts were found in reperfused dogs given metoprolol, but the differences from dogs receiving rt-PA alone were not statistically significant (I/LV, expressed as mean +/- SEM: 5.5 +/- 0.9% in group I, 6.7 +/- 1.9% in group II, 15.4 +/- 5.0% in group III, 11.4 +/- 3.5% in group IV, 23.6 +/- 2.5% in group V, and 26.9 +/- 2.3% in group VI).(ABSTRACT TRUNCATED AT 250 WORDS)
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42
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Goldberg RJ, Gore JM, Alpert JS, Dalen JE. Non-Q wave myocardial infarction: recent changes in occurrence and prognosis--a community-wide perspective. Am Heart J 1987; 113:273-9. [PMID: 3442573 DOI: 10.1016/0002-8703(87)90265-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A community-wide study of patients hospitalized with validated acute myocardial infarction (MI) in all 16 hospitals in the Worcester metropolitan area, during the calendar years 1975, 1978, and 1981, is examining time trends in the incidence rates, in-hospital case fatality rates, and long-term survival rates of 2451 patients hospitalized with acute MI further classified into those with Q wave and those with non-Q wave MI. The age-adjusted hospital attack rates (per 100,000) of initial events of Q wave MI increased from 153 in 1975 to 197 in 1981 (p less than 0.05), while the attack rates of non-Q wave MI increased from 46 in 1975 to 89 in 1981 (p less than 0.001). Patients with non-Q wave MI were at significantly decreased risk of dying during hospitalization (12.0%) as compared to those with Q wave MI (25.2%), overall as well as for each of the three time periods studied (p less than 0.05). For patients discharged alive from the hospital, however, there were no significant differences in long-term survival rates according to MI type over an 8-year follow-up period. These results, obtained from a community-wide sample of patients with validated acute MI, indicate a significant change in the occurrence rates and/or recognition of non-Q wave MI, a significantly lower in-hospital case fatality rate for patients with non-Q wave MI, and comparable long-term prognosis for patients with Q wave and non-Q wave acute MI.
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Abstract
Despite more than 15 years of intensive experimental and clinical research in the general area of limiting infarct size, no treatment has been shown to be so efficacious and relatively free of side effects that its routine use can be recommended. In addition, there is no ideal means of measuring infarct size as yet. However, considerable progress has been made in understanding mechanisms responsible for irreversible cellular injury and in identifying factors and anatomic alterations responsible for or contributing to the development of transmural (Q wave) and non-transmural (non-Q wave) myocardial infarcts. Interventions are available that are capable of causing rapid coronary thrombolysis, and techniques are becoming available tht have increasing power to size myocardial infarcts and estimate both segmental and ventricular function. Experimental studies have also suggested a potential benefit from a combination of reperfusion therapy with selected pharmacologic intervention in reducing infarct size and preserving ventricular function. It seems likely that this general area will remain an intensive area of clinical research in the immediate future.
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Endo T, Nejima J, Fujita S, Kiuchi K, Iida N, Kikuchi K, Hayakawa H, Okumura H. Comparative effects of nicardipine, a new calcium antagonist, on size of myocardial infarction after coronary artery occlusion in dogs. Circulation 1986; 74:420-30. [PMID: 3731430 DOI: 10.1161/01.cir.74.2.420] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
To examine whether nicardipine, a dihydropyridine derivative, limits size of myocardial infarction, and to compare the protective effects of nicardipine administered before and early and late after coronary artery occlusion, 99mTc-labeled albumin microspheres were injected into the left atrium during 5 min temporary coronary artery occlusion to determine the extent of the hypoperfused zone (the area at risk). The coronary arteries were then reperfused for 45 min before 6 hr permanent coronary artery occlusion. Fifteen minutes before permanent occlusion, dogs were randomly assigned to a control group (n = 11), a pretreatment group (n = 9), which received at this point 10 micrograms/kg of nicardipine as a loading dose followed by a continuous infusion of 8 micrograms/kg/hr for 6 hr, an early treatment group (n = 9), in which nicardipine treatment was initiated 15 min after occlusion, or a late treatment group (n = 8), in which nicardipine administration was delayed for 3 hr. Six hours after coronary artery occlusion, the hearts were excised and the left ventricle of each was cut into 3 mm thick slices and stained with triphenyltetrazolium chloride. The extent of myocardial necrosis was measured by planimetry of the unstained areas. Thereafter, the same slices were autoradiographed and the extent of the hypoperfused zone was measured by planimetry of the "cold spot." The extent of the hypoperfused zone was identical among the four groups. In the control group, the ratio of the extent of myocardial necrosis to the extent of the hypoperfused zone was 95.8 +/- 3.8% (mean +/- SEM). However, it was significantly smaller in the pretreatment group (59.9 +/- 13.3%, p less than .05) and the early treatment group (49.0 +/- 10.6%, p less than .01) than in the control group. In the late treatment group, this value was not different from that in the control group (86.5 +/- 7.1%). There was a close inverse correlation between reduction of infarct size and the extent of the hypoperfused zone in the pretreatment and early treatment groups. Thus, nicardipine administered before or early after coronary artery occlusion limited infarct size by 37% to 49%, whereas when administration was delayed for 3 hr infarct size was not reduced. Furthermore, nicardipine had more striking effects on the ischemic myocardium of dogs with small hypoperfused zones than on that of dogs with large hypoperfused zones.
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45
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Miyazawa K, Fukuyama H, Komatsu E, Yamaguchi I. Effects of propranolol on myocardial damage resulting from coronary artery occlusion followed by reperfusion. Am Heart J 1986; 111:519-24. [PMID: 3953361 DOI: 10.1016/0002-8703(86)90057-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
To evaluate the effects of propranolol on myocardial metabolism after coronary reperfusion, serial measurements of myocardial creatine kinase (CK) and calcium (Ca) contents and CK and lactic acid (LA) concentrations in coronary sinus blood were carried out in 33 open-chest dogs. The left anterior descending coronary artery was occluded for 60 minutes and was then reopened. Twelve of the dogs were given propranolol before occlusion. Reperfusion for 30 minutes in dogs with and without propranolol pretreatment resulted in reduced myocardial CK in the ischemic region and rapidly elevated plasma CK and LA. However, when compared with the control group, the propranolol-treated group showed smaller changes in myocardial CK and plasma LA. Myocardial Ca in the ischemic region was significantly higher than that in the nonischemic region in the control group, but not in the propranolol-treated group. It was concluded that propranolol was protective against myocardial damage resulting from coronary occlusion followed by reperfusion.
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46
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Brown MA, Norris RM, Barnaby PF, Geary GG, Brandt PW. Effect of early treatment with propranolol on left ventricular function four weeks after myocardial infarction. Heart 1985; 54:351-6. [PMID: 4052276 PMCID: PMC481909 DOI: 10.1136/hrt.54.4.351] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Left ventricular function and exercise capacity were assessed in 79 patients randomised to receive intravenous and oral propranolol (n = 44) or conventional therapy (n = 35) within four hours of onset of their first myocardial infarction. Cineangiocardiography and exercise testing were performed four weeks after infarction to allow for maximum recovery of myocardial function. Left ventriculography showed no improvement in ejection fraction or preservation of regional contractile function in patients treated with propranolol compared with controls. A trend towards smaller end diastolic volumes was seen in the propranolol group (mean (SD) 151(42) ml) compared with controls (167(42) ml). Exercise duration and frequency of angina were not significantly different in the two groups. It is concluded that limitation of infarct size by propranolol does not lead to a significant improvement in ventricular systolic function, although left ventricular dilatation may be reduced. These findings are consistent with the known effect of early intravenous beta blockade which limits infarct size by preservation of subepicardial myocardium.
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47
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Bullock GR, Leprán I, Parratt JR, Szekeres L, Wainwright CL. Effects of a combination of metoprolol and dazmegrel on myocardial infarct size in rats. Br J Pharmacol 1985; 86:235-40. [PMID: 4052726 PMCID: PMC1916875 DOI: 10.1111/j.1476-5381.1985.tb09454.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The effects of acute pretreatment with metoprolol, dazmegrel and a combination of these two drugs has been examined on myocardial infarct size in rats. Ischaemic damage was assessed 4 h after coronary artery occlusion in anaesthetized rats and after 48 h of ischaemia in conscious rats. Infarct size was measured histochemically (by using periodic-acid-Schiff diastase reaction for glycogen) and by standard histological examination (haematoxylin and eosin stain). There was some evidence of protection of the myocardium by metoprolol following 4 h of ischaemia (determined histologically) but this was not apparent 48 h after occlusion. When given alone, dazmegrel had no significant effects on infarct size assessed by either method. A clear reduction in the extent of glycogen depletion and histological damage was observed with the combination of metoprolol and dazmegrel 48 h after the onset of ischaemia. This protection was seen to occur in the horizontal plane of the heart, preventing the extension of the infarct towards the posterior wall of the left ventricle and showing some salvage of the epicardial surfaces.
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48
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Ciuffo AA, Ouyang P, Becker LC, Levin L, Weisfeldt ML. Reduction of sympathetic inotropic response after ischemia in dogs. Contributor to stunned myocardium. J Clin Invest 1985; 75:1504-9. [PMID: 3998147 PMCID: PMC425489 DOI: 10.1172/jci111854] [Citation(s) in RCA: 66] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Eight open chest dogs underwent 25 min of coronary occlusion to determine whether brief myocardial ischemia disrupts the normal myocardial inotropic response to sympathetic nervous stimulation. If so, this could represent a mechanism contributing to postischemic myocardial dysfunction. Myocardial segment shortening was measured using ultrasonic dimension crystals before and after coronary artery occlusion and reperfusion. Left ansa subclavia stimulation and systemic norepinephrine (NE) infusion were used to test the myocardial inotropic response to neural stimulation and direct exposure to the sympathetic mediator, respectively. Before coronary artery occlusion, base-line preischemic segment shortening (12.5 +/- 1.6%) (SEM) increased during both sympathetic stimulation (20.2 +/- 1.4%) and NE infusion (19.7 +/- 1.1%). The control segment responded similarly. After ischemia and reperfusion there was no significant change in heart rate, aortic or left ventricular pressures, nor changes in control segment shortening. In contrast, shortening in the postischemic segment was markedly reduced compared to baseline (4.1 +/- 2.4%), and no longer responded to sympathetic stimulation (2.4 +/- 2.8%), while responsiveness to systemic NE was maintained (12.9 +/- 2.0%), P less than 0.001, which suggested injury to the sympathetic-neural axis during the period of ischemia. This reduced response to neural stimulation was persistent for up to 2 h after reperfusion. Left atrial or intracoronary infusion of bretylium tosylate, which releases norepinephrine from nerve terminals, resulted in an immediate inotropic response in the postischemic segment, which indicated that total depletion of NE from nerve terminals during the ischemic period had not occurred. Disruption of sympathetic neural responsiveness is likely a component of the mechanism of postischemic myocardial dysfunction whenever there is appreciable sympathetic drive to the heart.
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Slutsky RA, Peck WW. Effects of beta-adrenergic blockade on the natural progression of myocardial infarct size and compensatory hypertrophy. J Am Coll Cardiol 1985; 5:1132-7. [PMID: 3157734 DOI: 10.1016/s0735-1097(85)80015-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Using contrast-enhanced computed tomography, the effects of beta-adrenergic blockade were assessed on experimentally produced myocardial infarcts in dogs evaluated serially over the course of approximately 1 month. Infarct size, initial perfusion defect (jeopardized segment) and noninfarcted muscle mass were studied in two groups of conditioned mongrel dogs. Group 1 (n = 11) served as the control group and Group 2 (n = 10) was pretreated with propranolol (2 mg/kg). Each animal in the propranolol-treated group was given identical amounts of the agent twice daily for 7 days after coronary occlusion. Both groups developed increases in the noninfarcted muscle mass of the left ventricle (compensatory hypertrophy). The mean increase averaged 19.8% over 30 days when the two groups were included together. Infarct size was smaller in the propranolol-treated group, and averaged 28% less (p less than 0.05) than that of the control group 30 days after initial myocardial infarction. Thus, pharmacologic interventions were shown by computed tomography to alter the size of an acute experimental myocardial infarct, particularly when examined over the time course of infarct healing. Moreover, compensatory hypertrophy occurred in both the control and propranolol-treated groups.
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50
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Yoshida S, Downey JM, Friedman FR, Chambers DE, Hearse DJ, Yellon DM. Nifedipine limits infarct size for 24 hours in closed chest coronary embolized dogs. Basic Res Cardiol 1985; 80:76-87. [PMID: 3985927 DOI: 10.1007/bf01906746] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We studied the ability of nifedipine, a calcium antagonist, to limit infarct size in the closed chest, coronary embolized dog. Immediately after embolization 141Ce labelled microspheres were administered into the left ventricle. Myocardium not receiving microspheres was considered to be the region at risk. The nifedipine group (10 dogs) received a bolus (16 micrograms/kg i.v. over 8 minutes as a loading dose) followed by continuous infusion (1,000 micrograms/24 hours) 10 min after embolization. The control group (9 dogs) received an equal volume of saline. Twenty-four hours after embolization the dogs were sacrificed, the heart sectioned into 4-mm slices and the slices were stained with tetrazolium to reveal the infarct. The region at risk was determined by autoradiography of the microspheres in the heart slices. Infarct and risk zone volume were determined by planimetric methods. The nifedipine group had a significantly smaller infarct volume to risk zone volume ratio than the control group (38.7 +/- 4.7% vs. 79.5 +/- 4.3%, p less than 0.001). We conclude that nifedipine produces a sustained limitation of infarct size following permanent occlusion of a dog's coronary artery.
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