Ultrastructural Cardiac Pathology: The Wide (yet so very small) World of Cardiac Electron Microscopy

Electron microscopy (EM) was a popular diagnostic tool in the 1970s and early 80s. With the adoption of newer, less expensive techniques, such as immunohistochemistry, the role of EM in diagnostic surgical pathology has dwindled substantially. Nowadays, even in academic centers, EM interpretation is relegated to renal pathologists and the handful of (aging) pathologists with experience using the technique. As such, EM interpretation is truly arcane-understood by few and mysterious to many. Nevertheless, there remain situations in which EM is the best or only ancillary test to ascertain a specific diagnosis. Thus, there remains a critical need for the younger generation of surgical pathologists to learn EM interpretation. Recognizing this need, cardiac EM was made the theme of the Cardiovascular Evening Specialty Conference at the 2023 United States and Canadian Academy of Pathology (USCAP) annual meeting in New Orleans, Louisiana. Each of the speakers contributed their part to this article, the purpose of which is to review EM as it pertains to myocardial tissue and provide illustrative examples of the spectrum of ultrastructural cardiac pathology seen in storage/metabolic diseases, cardiomyopathies, infiltrative disorders, and cardiotoxicities.

Pharmacological inhibition of translocon is sufficient to alleviate endoplasmic reticulum stress and improve Ca2+ handling and contractile recovery of stunned myocardium

INTRODUCTION

The function of endoplasmic reticulum (ER), a Ca²⁺ storage compartment and site of protein folding, is altered by disruption of intracellular homeostasis. Misfolded proteins accumulated in the ER lead to ER stress (ERS), unfolded protein response (UPR) activation and ER Ca²⁺ loss. Myocardial stunning is a temporary contractile dysfunction, which occurs after brief ischemic periods with minimal or no cell death, being oxidative stress and Ca²⁺ overload potential underlying mechanisms. Myocardial stunning induces ERS response with negatively impact on the post-ischemic mechanical performance through an unknown mechanism.

AIMS

In this study, we explored whether ER Ca²⁺ efflux through the translocon, a major Ca²⁺ leak channel, contributes to Ca²⁺ mishandling and the consequent contractile abnormalities of the stunned myocardium.

METHODS

Mechanical performance, cytosolic Ca²⁺, UPR markers and oxidative state were evaluated in perfused rat/mouse hearts subjected to a brief ischemia followed by reperfusion (I/R) in absence or presence of the translocon inhibitor, emetine (1 μM), comparing its effects with those of the chaperones TUDCA (30 μM) and 4-PBA (3 mM).

RESULTS

Emetine treatment precluded the I/R-induced increase in UPR signaling markers and improved the contractile recovery together with a remarkable attenuation in myocardial stiffness when compared to I/R hearts with no drug. This alleviation of I/R-induced mechanical abnormalities was more effective than that obtained with the chemical chaperones, TUDCA and 4-PBA. Moreover, emetine treatment produced a striking improvement in diastolic Ca²⁺ handling with a partial recovery of the I/R-induced oxidative stress.

CONCLUSION

Blocking ER Ca²⁺ store depletion via translocon suppressed ER stress and improved mechanical performance and diastolic Ca²⁺ handling of stunned myocardium. Modulation of translocon permeability emerges as a therapeutic approach to face dysfunctional consequences of the I/R injury.

Synthesis and Characterization of N-(2-Hydroxypropyl)-Methacrylamide (HPMA) Copolymer-Emetine Conjugates

The plant alkaloid emetine has considerable potential as an antitumor agent, but early attempts to develop the compound clinically failed due to unacceptable dose limiting toxicity and poorly reproducible results. This study reports the synthesis and characterization of novel N-(2-hydroxypropyl)methacrylamide (HPMA) copolymer conjugates containing emetine. The drug was linked to the polymer via biodegradable (Gly-Phe-Leu-Gly) and non-degradable (Gly-Gly) peptidyl linkers. HPMA-Gly-Gly emetine conjugate was found to contain 8% (w/w) of bound emetine, while emetine loading of HPMA-Gly-Phe-Leu-Gly-emetine was found to be 19% (w/w). Due to the change in cellular pharmacokinetics, polymer conjugates are invariably less toxic than free drug, in vitro and HPMA copolymer-emetine conjugates were no exception. Conjugates containing the biodegradable Gly-Phe-Leu-Gly linker displayed an IC50 of 90 μg/mL towards L1210 leukemia cells which is 225 less toxic than free emetine (IC50 = 0.4 μg/mL). Against B16F10 melanoma the conjugate was 60 times less toxic than free drug (IC50 of 300 and 5 μg/mL respectively). In contrast, the conjugate containing a non-biodegradable (Gly-Gly) linker showed very low or no activity in vitro. Although the conjugates showed no significant effect on the rate of tumor growth, the HPMA-Gly-Gly-emetine prodrug had a significant effect on the survival time of animals bearing L1210 tumors. Here we describe the first polymer conjugates containing emetine. Further studies are warranted to document the spectrum of antitumor activity, dose-limiting toxicity and pharmacokinetics of HPMA copolymer-emetine in vivo.

Targeting tumor suppressor genes for cancer therapy

Cancer drugs are broadly classified into two categories: cytotoxic chemotherapies and targeted therapies that specifically modulate the activity of one or more proteins involved in cancer. Major advances have been achieved in targeted cancer therapies in the past few decades, which is ascribed to the increasing understanding of molecular mechanisms for cancer initiation and progression. Consequently, monoclonal antibodies and small molecules have been developed to interfere with a specific molecular oncogenic target. Targeting gain-of-function mutations, in general, has been productive. However, it has been a major challenge to use standard pharmacologic approaches to target loss-of-function mutations of tumor suppressor genes. Novel approaches, including synthetic lethality and collateral vulnerability screens, are now being developed to target gene defects in p53, PTEN, and BRCA1/2. Here, we review and summarize the recent findings in cancer genomics, drug development, and molecular cancer biology, which show promise in targeting tumor suppressors in cancer therapeutics.

Gender differences in non-ischemic myocardial remodeling: are they due to estrogen modulation of cardiac mast cells and/or membrane type 1 matrix metalloproteinase

This review is focused on gender differences in cardiac remodeling secondary to sustained increases in cardiac volume (VO) and generated pressure (PO). Estrogen has been shown to favorably alter the course of VO-induced remodeling. That is, the VO-induced increased extracellular matrix proteolytic activity and mast cell degranulation responsible for the adverse cardiac remodeling in males and ovariectomized rodents do not occur in intact premenopausal females. While less is known regarding the mechanisms responsible for female cardioprotection in PO-induced stress, gender differences in remodeling have been reported indicating the ability of premenopausal females to adequately compensate. In view of the fact that, in male mice with PO, mast cells have been shown to play a role in the adverse remodeling suggests favorable estrogen modification of mast cell phenotype may also be responsible for cardioprotection in females with PO. Thus, while evidence is accumulating regarding premenopausal females being cardioprotected, there remains the need for in-depth studies to identify critical downstream molecular targets that are under the regulation of estrogen and relevant to cardiac remodeling. Such studies would result in the development of therapy which provides cardioprotection while avoiding the adverse effects of systemic estrogen delivery.

The effects of baicalein on canine osteosarcoma cell proliferation and death

Flavonoids are a group of modified triphenolic compounds from plants with medicinal properties. Baicalein, a specific flavone primarily isolated from plant roots (Scutellaria baicalensis), is commonly used in Eastern medicine for its anti-inflammatory and antineoplastic properties. Previous research shows greater efficacy for baicalein than most flavonoids; however, there has been little work examining their effects on sarcoma cells, let alone canine cells. Three canine osteosarcoma cell lines (HMPOS, D17 and OS 2.4) were treated with baicalein to examine cell viability, cell cycle kinetics, anchorage-independent growth and apoptosis. Results showed that osteosarcoma cells were sensitive to baicalein at concentrations from approximately 1 to 25 μM. Modest cell cycle changes were observed in one cell line. Baicalein was effective in inducing apoptosis and did not prevent doxorubicin cell proliferation inhibition in all the cell lines. The mechanism for induction of apoptosis has not been fully elucidated; however, changes in mitochondrial permeability supersede the apoptotic response.

High-density real-time PCR-based in vivo toxicogenomic screen to predict organ-specific toxicity

Toxicogenomics, based on the temporal effects of drugs on gene expression, is able to predict toxic effects earlier than traditional technologies by analyzing changes in genomic biomarkers that could precede subsequent protein translation and initiation of histological organ damage. In the present study our objective was to extend in vivo toxicogenomic screening from analyzing one or a few tissues to multiple organs, including heart, kidney, brain, liver and spleen. Nanocapillary quantitative real-time PCR (QRT-PCR) was used in the study, due to its higher throughput, sensitivity and reproducibility, and larger dynamic range compared to DNA microarray technologies. Based on previous data, 56 gene markers were selected coding for proteins with different functions, such as proteins for acute phase response, inflammation, oxidative stress, metabolic processes, heat-shock response, cell cycle/apoptosis regulation and enzymes which are involved in detoxification. Some of the marker genes are specific to certain organs, and some of them are general indicators of toxicity in multiple organs. Utility of the nanocapillary QRT-PCR platform was demonstrated by screening different references, as well as discovery of drug-like compounds for their gene expression profiles in different organs of treated mice in an acute experiment. For each compound, 896 QRT-PCR were done: four organs were used from each of the treated four animals to monitor the relative expression of 56 genes. Based on expression data of the discovery gene set of toxicology biomarkers the cardio- and nephrotoxicity of doxorubicin and sulfasalazin, the hepato- and nephrotoxicity of rotenone, dihydrocoumarin and aniline, and the liver toxicity of 2,4-diaminotoluene could be confirmed. The acute heart and kidney toxicity of the active metabolite SN-38 from its less toxic prodrug, irinotecan could be differentiated, and two novel gene markers for hormone replacement therapy were identified, namely fabp4 and pparg, which were down-regulated by estradiol treatment.

Morphologic aspects of rodent cardiotoxicity in a retrospective evaluation of National Toxicology Program studies

The heart is increasingly recognized as a target for toxicity. As studies in laboratory rodents are commonly used to investigate the potential toxicity of various agents, the identification and characterization of lesions of cardiotoxicity is of utmost importance. Although morphologic criteria have been established for degenerative myocardial lesions in rats and mice, differentiation of spontaneously occurring lesions from toxin-induced or toxin-related lesions remains difficult. A retrospective light microscopic evaluation was performed on the hearts of F344 rats and B6C3F(1) mice from National Toxicology Program (NTP) studies of six chemicals identified in the NTP database in which treatment-induced myocardial toxicity was present. Two previously defined myocardial lesions were observed: "cardiomyopathy" that occurred spontaneously or as a treatment-related effect and "myocardial degeneration" that occurred as a treatment-related effect. Both lesions consisted of the same basic elements, beginning with myofiber degeneration and necrosis, with varying amounts of inflammation, interstitial cell proliferation, and eventual fibrosis. This observation is indicative of the heart's limited repertoire of responses to myocardial injury, regardless of the nature of the inciting agent. A prominent differentiating factor between spontaneous and treatment-induced lesions was distribution and lesion onset. Once the respective lesions had undergone fibrosis, however, they generally appeared morphologically indistinguishable.

Rapidly reversible cardiomyopathy associated with chronic ipecac ingestion

Ipecac, an over-the-counter emetic agent, has been a drug of choice for abuse by patients with eating disorders. Its alkaloid emetine has been associated with serious cardiac toxicity; however, the dose effect has not been well established. We present a patient with anorexia and bulimia nervosa who ingested ipecac chronically and developed the characteristic manifestations of ipecac toxicity. Unexpectedly, her induced left ventricular dysfunction returned to normal after only 10 days of withholding the drug. This finding, in contrast with the findings of other reports, establishes that ipecac cardiomyopathy can be readily reversible. The cumulative experience thus far, nonetheless, provides no discernible pattern of the effect of ipecac on the myocardium. Thus, in the continuum of poisoning, the point at which the myocardium becomes irreversibly damaged is undetermined. With continued abuse, potentially lethal outcome, and limited experience with ipecac cardiotoxicity, further investigation and perhaps heightened restriction of the drug are warranted.

Effects of pyridine exposure upon structural lipid metabolism in Swiss Webster mice

Pyridine is a prototypical inducer of cytochrome P450 (CYP) 2E1, an enzyme associated with cellular oxidative stress and membrane damage. To better understand the effect of this treatment on cellular lipids, the influence of pyridine exposure (100 mg/kg/day i.p. for 5 days) on fatty acids, fatty esters, and fatty alcohol ethers in brain, heart, liver, and adipose tissue from male Swiss Webster mice was investigated. Lipid levels in cholesterol esters, triglycerides, free fatty acids, cardiolipin, sphingomyelin, and glycerylphospholipids were quantified. Pyridine altered the level and composition of lipids involved in membrane structure (i.e., sphingomyelin, phosphatidylethanolamines, and plasmalogens), energy metabolism (i.e., free fatty acids), and long-chain fatty acid transport (i.e., cholesterol esters) in a tissue-specific manner. Subtle changes in cholesterol esters were observed in all tissues. Sphingomyelin in the brain and heart were depleted in monounsaturated fatty acids (1.4- and 1.5-fold, respectively), while the liver sphingomyelin concentrations increased (1.5-fold). Pyridine exposure also increased heart free fatty acids by 1.3-fold, enriched cardiac phosphatidylethanolamine in long-chain polyunsaturated fatty acids by 1.3-fold, and depleted cardiolipin-associated plasmalogens by 3.8-fold. Phosphatidylethanolamines in the brain were also enriched in both saturated fatty acids (1.2-fold) and polyunsaturated fatty acids (1.3-fold) but were depleted in plasmalogens (2.9-fold). In particular, the levels of phosphatidylethanolamine-associated arachidonic (AA) and docosahexaenoic acid (DHA) in both brain and cardiac tissues significantly decreased following pyridine exposure. Considering the hypothetical role of plasmalogens as membrane-bound reactive oxygen scavengers, the current findings suggest that the brain and heart should be the focus of future studies on the toxicity of pyridine, as well as other CYP 2E1 inducers.

Modafinil and cocaine: a double-blind, placebo-controlled drug interaction study

Modafinil is a novel compound that is approved for the treatment of narcolepsy. It is now being studied as a potential treatment for cocaine dependence. Cocaine withdrawal symptoms are associated with poor clinical outcome and are likely to be reversed by modafinil. In addition, the neurotransmitter actions of modafinil are opposite to cocaine-induced neuroadaptations affecting dopamine and glutamate reward circuits. Since cocaine-dependent subjects might use cocaine during a clinical trial with modafinil, this study tested the safety of intravenous cocaine (30 mg) in combination with modafinil. Each of seven subjects received a baseline (open-label) cocaine infusion. Three subsequent cocaine infusions were administered after subjects received 4 days of low dose modafinil (200 mg/day), high dose modafinil (400 mg/day), or placebo in randomized double-blind sequences. One subject received placebo prior to all infusions. Our results indicate that co-administering modafinil and a single dose of intravenous cocaine is not associated with medical risk in terms of blood pressure, pulse, temperature, or electrocardiogram measures. Furthermore, pretreatment with modafinil did not intensify cocaine euphoria or cocaine-induced craving. In fact, cocaine euphoria was significantly blunted (P=0.02) in one of our subjective measures.

Cardiovascular manifestations of substance abuse part 1: cocaine

Substance abuse with cocaine is associated with multiple cardiovascular conditions, including myocardial infarction, dissection, left ventricular hypertrophy, arrhythmias, sudden death, and cardiomyopathy. Cocaine has effects to potentiate the physiologic actions of catecholamines and has direct effects on voltage-dependent sodium ion channels related to local anesthetic properties. The effects of cocaine can be augmented with concomitant alcohol consumption. Acute myocardial ischemia caused by cocaine may be related to in situ thromboisis and/or coronary vasospasm. Treatment strategies for cocaine-induced myocardial infarction would include antiplatelet therapy, thrombolysis, and vasodilators (eg, nitrates, nifedipine). Beta-adrenergic blockers should not be used unless concomitant vasodilator therapy is given.

Green tea extracts can counteract the modification of fatty acid composition induced by doxorubicin in cultured cardiomyocytes

Doxorubicin cardiotoxicity is associated with the generation of free radicals, and involves not only lipid peroxidation but also a decreased biosynthesis of highly unsaturated fatty acids, leading to significant modification in cardiomyocyte fatty acid composition. We have evaluated whether naturally occurring antioxidants could counteract this side-effect. Green tea is an excellent source of catechins; we supplemented cultured rat cardiomyocytes with different green tea extracts to relate their catechin content and composition to their ability in protecting cells against doxorubicin-induced damage. The determination of total lipid fatty acid composition, of conjugated diene production (indicator of lipid peroxidation), and of lactate dehydrogenase release revealed that supplementation with tea extracts could counteract significant modifications in the fatty acyl pattern due to doxorubicin exposure, although to different extents. These differences could be ascribed to the different total catechin content and to qualitative differences among the tea extracts, determined by HPLC analysis.

Diminished molecular response to doxorubicin and loss of cardioprotective effect of dexrazoxane inEgr-1deficient female mice

Doxorubicin (DOX) and VP16 are DNA topoisomerase II inhibitors yet only DOX induces an irreversible cardiotoxicity, likely through DOX-induced oxidative stress. Egr-1 is overexpressed after many stimuli that increase oxidative stress in vitro and after DOX-injection into adult mice in vivo. To investigate Egr-1 function in the heart, we compared the molecular and histological responses of wild type (+/+) and Egr-1 deficient (–/–) female mice to saline, DOX, VP16, the cardioprotectant dexrazoxane (DZR), or DOX+DZR injection. DOX, and to a lesser extent VP16, induced characteristic increases in cardiac muscle and non-muscle genes typical of cardiac damage in +/+ mice, whereas only β-MHC and Sp1 were increased in –/– mice. DZR-alone treated +/+ mice showed increased cardiomyocyte transnuclear width without a change to the heart to body weight (HW/BW) ratio. However, DZR-alone treated –/– mice had an increased HW/BW, increased cardiomyocyte transnuclear width, and gene expression changes similar to DOX-injected +/+ mice. DZR pre-injection alleviated DOX-induced gene changes in +/+ mice; in DZR+DOX injected –/– mice the increases in cardiac and non-muscle gene expression were equal to, or exceeded that, detected after DOX-alone or DZR-alone injections. We conclude that Egr-1 is required for DOX-induced molecular changes and for DZR-mediated cardioprotection.Key words: mice, gene expression, doxorubicin, DNA topoisomerase II inhibitors, cardioprotection.

Role of gamma-linolenic acid in counteracting doxorubicin-induced damage in cultured rat cardiomyocytes

The clinical usefulness of doxorubicin is limited by cardiotoxicity. We have demonstrated that doxorubicin has a dual negative effect on myocardial lipids, acting against highly unsaturated fatty acids (HUFAs) directly and desaturating/elongating enzymes required for their biosynthesis, thus decreasing linoleic and alpha -linolenic conversion to higher metabolites. Primary cultures of rat cardiomyocytes were challenged with different doxorubicin concentrations and doxorubicin exposure was followed by a 24-h recovery period in the absence or presence of serum, and of gamma -linolenic acid. Serum in the recovery medium did not appear to be essential for the restoration of the desaturating/elongating activities, and gamma -linolenic acid supplementation influenced only alpha -linolenic acid conversion. Serum, and particularly gamma-linolenic acid, were very important in increasing HUFA levels behind the pure biosynthesis. HUFA biosynthesis plays a role in counteracting doxorubicin toxicity, but it cannot completely overcome the depletion of these fatty acids; serum and exogenous gamma-linolenate are critical in filling the decreased HUFA pool.

TAFII250, Egr-1, and D-type cyclin expression in mice and neonatal rat cardiomyocytes treated with doxorubicin

Differential display identified that gene fragment HA220 homologous to the transcriptional activator factor II 250 (TAFII250) gene, or CCG1, was increased in hypertrophied rodent heart. To determine whether TAFII250 gene expression is modified after cardiac damage, we measured TAFII250 expression in vivo in mouse hearts after injection of the cardiotoxic agent doxorubicin (DXR) and in vitro in DXR-treated isolated rat neonatal cardiomyocytes. In vivo atrial natriuretic factor (ANF), beta-myosin heavy chain (beta-MHC), Egr-1, and TAFII250 expression increased with dose and time after a single DXR injection, but only ANF and beta-MHC expression were increased after multiple injections. After DXR treatment of neonatal cardiomyocytes we found decreased ANF, alpha-MHC, Egr-1, and TAFII250 expression. Expression of the TAFII250-regulated genes, the D-type cyclins, was increased after a single injection in adult mice and was decreased in DXR-treated cardiomyocytes. Thus expression of Erg-1, TAFII250, and the D-type cyclins is modulated after cardiotoxic damage in adult and neonatal heart.

Dexrazoxane: A New Cardioprotective Agent

Objective:

To review the literature discussing the use of dexrazoxane (e.g., Zinecard, ICRF-187) to prevent doxorubicin-induced cardiotoxicity.

Data Sources:

Pertinent English-language reports of studies in humans were retrieved from a MEDLINE search (January 1980-January 1997); search terms included chelating agents, razoxane, dexrazoxane, Zinecard, ICRF-187, ADR-529, and ICRF-159.

Study Selection:

Representative articles discussing the chemistry, pharmacology, pharmacokinetics, dosing, and administration of dexrazoxane and those discussing clinical trials were selected.

Data Extraction:

Data were extracted and analyzed if the information was relevant and consistent. Studies were selected for review in the text on the basis of study design and clinical end points.

Data Synthesis:

Dexrazoxane is a chemoprotective agent developed to prevent cardiac tissue toxicity. Dexrazoxane exerts a cardioprotective effect with some clinically significant toxicities; it may also interfere with the antitumor activity of doxorubicin. Until there are sufficient data to support its use in first-line supportive care therapy, dexrazoxane should be reserved for use in patients responding to doxorubicin-based chemotherapy but who have risk factors for cardiac toxicity or have received a cumulative doxorubicin bolus dose of 300 mg/m2.

Conclusions:

The management of doxorubicin-induced cardiotoxicity has led to the development of supportive care drugs that specifically counteract the dose-limiting toxicities. Dexrazoxane may not completely eliminate the concern about doxorubicin-induced cardiotoxicity, but it may open new avenues for continuing doxorubicin-based chemotherapy.

Mechanism of sodium channel blockade in the cardiotoxic action of emetine dihydrochloride in isolated cardiac preparations and ventricular myocytes of guinea pigs

Emetine is used in the therapy of special forms of amebiasis and is abused as syrup of ipecac by persons with bulimia. Severe cardiac side effects were reported. Thus the intracellular microelectrode technique and the patch-clamp technique in the cell-attached mode were used to study the effects of emetine on the action potential and upstroke velocity (Vmax) in papillary muscles and Purkinje fibers of guinea pigs as well as on macroscopic and (S)-DPI 201-106-modified and unmodified single-sodium-channel current (I(Na)) of guinea-pig ventricular myocytes. Emetine caused a tonic block of Vmax and reduced I(Na) independent of frequency. Hill plots were linear, with slopes ranging from 0.96 to 1.06, suggestive of a first-order reaction. The current-voltage relation was not influenced, indicating a voltage-independent blockade of the sodium channels. The most prominent effects were an increase of sweeps without activity, a decrease of the fast component of the open-time distribution, an increase of the slow component of the closed-time distribution, and a reduction in the number of bursts per record. The amplitude of the unitary current was not changed. From the results, we conclude that I(Na) blockade contributes to the cardiotoxicity of emetine.

Acute presynaptic inhibition by doxorubicin of negative chrono- and inotropic responses to parasympathetic nerve stimulation in isolated, blood-perfused dog atrium

The clinical use of doxorubicin, an anthracycline antineoplastic agent, is limited by its cardiotoxicity. Although several previous reports have shown neurotoxic effects of doxorubicin, there is little information about the acute effects of doxorubicin on the autonomic nerve functions in the heart. Accordingly, to evaluate the effects of doxorubicin on the cardiac responses to autonomic nerve activation, we studied the effects of doxorubicin on the negative chrono- and inotropic responses to intracardiac parasympathetic nerve stimulation and acetylcholine (ACh), and the positive chrono- and inotropic responses to norepinephrine (NE) in the isolated, blood-perfused dog atrium. Doxorubicin (0.01-3 mumol), injected into the sinus node artery of the isolated atrium, induced negative inotropic effects dose dependently and weak negative chronotropic effects. Doxorubicin inhibited the negative chrono- and inotropic responses to parasympathetic nerve stimulation dose dependently. However, doxorubicin affected neither the negative chrono- and inotropic responses to ACh nor the positive chrono- and inotropic responses to NE. These results indicate that doxorubicin interacts with neither muscarinic receptors nor beta-adrenoceptors and suggest that doxorubicin inhibits the negative cardiac responses to parasympathetic nerve activation due to the inhibition of ACh release from nerve varicosities in the heart.

Cardiotoxicity of emetine dihydrochloride by calcium channel blockade in isolated preparations and ventricular myocytes of guinea-pig hearts

1. The cardiotoxic effects of emetine dihydrochloride on mechanical and electrical activity were studied in isolated preparations (papillary muscles, sinoatrial and atrioventricular nodes, ventricular myocytes) of the guinea-pig heart. 2. Force of contraction was measured isometrically, action potentials and maximum rate of rise of the action potential were recorded by means of the intracellular microelectrode technique. Single channel L-type calcium current (Ba2+ ions as charge carrier) was studied with the patch-clamp technique in the cell-attached mode. 3. Emetine dihydrochloride (8-256 microM) reduced force of contraction in papillary muscles and spontaneous activity of sinoatrial and atrioventricular nodes concentration-dependently; the negative inotropic effect was abolished when the extracellular Ca2+ concentration was increased. 4. Maximum diastolic potential, action potential amplitude, maximum rate of rise of the action potential and the slope of the slow diastolic depolarization were decreased by emetine in sinoatrial as well as atrioventricular noes, while action potential duration was prolonged in both preparations (1-64 microM). 5. The amplitude of the L-type calcium single channel current was not altered by emetine dihydrochloride, while average open state probability was decreased concentration-dependently (10, 30 and 60 microM). 6. The most prominent effect of emetine dihydrochloride on single channel current was an increase of sweeps without activity. 7. At 60 microM, emetine dihydrochloride caused a decrease of the mean open time an increase of the mean closed time. The number of openings per record and number of bursts per record were reduced. 8. It is concluded that emetine dihydrochloride produces an L-type calcium channel block which might contribute to its cardiac side effects.

Effects of pharmacological interventions on emetine cardiotoxicity in isolated perfused rat hearts

The cardiotoxicity of emetine continues to be a significant clinical problem. The purpose of this study was to investigate the effect of several mechanistic interventions, including ICRF-187, an iron-chelating agent which protects against doxorubicin toxicity, atropine, and fructose-1,6-bisphosphate (FBP) on the toxicity of emetine in our isolated, perfused rat heart model. The model includes functional, electrocardiographic, and biochemical determinations in the same preparation. Atropine and ICRF-187 had no effect on the time needed for emetine to induce ventricular asystole, while FBP significantly increased this time. Administration of 47 microM atropine, 300 microM FBP, or 1 mM FBP decreased the release of lactate dehydrogenase (LDH) into the coronary effluent, while ICRF-187 had no effect. These pharmacological interventions variably changed the amplitude of the biphasic response of the coronary flow to emetine. Finally, FBP was very effective in slowing the rate of QRS-waveform degeneration in the perfused hearts. Emetine caused PR- and QRS-prolongation which was not altered by FBP.

Assessment of anthracycline-related myocardial adrenergic derangement by [123I]metaiodobenzylguanidine scintigraphy

Myocardial adrenergic neuron integrity and function were evaluated in 21 patients who had received doxorubicin or epirubicin for various malignancies. Myocardial uptake of iodine-123 metaiodobenzylguanidine ([123I]MIBG), a marker suitable for the study of myocardial neuron injury, was calculated from planar scintigraphic images after 4 h and the washout between 15 min and 4 h. In 13 patients with normal left ventricle ejection fraction (LVEF) analysed at three cumulative dose levels (no, low and middle dose), [123I]MIBG uptake tended to be significantly impaired (z = -2.772, P = 0.0056), at higher cumulative dose levels, before significant LVEF changes were observed. [123I]MIBG values were considerably decreased in 2/7 patients investigated at low cumulative dose and in 3/8 cases at the middle dose level. On follow-up, 1 of these patients, who had normal LVEF after completion of chemotherapy but whose [123I]MIBG values had progressively deteriorated during anthracycline therapy, subsequently developed congestive heart failure; another patient, whose [123I]MIBG values were impaired at the middle dose level, developed persistent reduced LVEF 5 months after completing therapy. In 8 patients, who had developed persistently, reduced LVEF at high doxorubicin cumulative dose levels, [123I]MIBG, performed in the period after chemotherapy discontinuation, was invariably abnormal. These data suggest that myocardial adrenergic derangement plays a role in anthracycline-associated cardiotoxicity: its appearance, even at low cumulative anthracycline dose levels, may reflect impairment of the intravesicular norepinephrine storage by incipient anthracycline-associated cardiac neuron injury. [123I]MIBG scintigraphy may be useful to assess myocardial adrenergic derangement during and in the follow-up of anthracycline therapy and potentially detect patients who are at risk.

Assessment of anthracycline cardiomyopathy by endomyocardial biopsy

Ultrastructural evaluation of endomyocardial biopsy specimens is a sensitive and effective method with which to detect and quantitate cardiotoxicity produced by anthracylines. The procedure and grading system used at the M.D. Anderson Cancer Center are described, and some of the pitfalls that may be encountered by the electron microscopist are reviewed.

In vitro evaluation of acute effects of mitoxantrone (Novantrone) in rat and guinea pig atria

Since guinea pig and rat atria have been used as models to study acute anthracycline-induced cardiotoxicity, experiments were carried out in these preparations to evaluate possible acute cardiac effects mediated by mitoxantrone (MTX). After a latency period of approximately 90 min, MTX (10(-5)-10(-4) M) promoted a concentration-related and time-dependent decrease of spontaneous rate in guinea pig atria. A similar but less intense effect after a longer latency interval was observed in rat atria. In this preparation, MTX (10(-5)-10(-4) M) incubated up to 150 min., induced a gradual competitive beta-adrenergic blocking effect on the positive chronotropic action of isoproterenol. This was characterized by a progressive decline of pD2 values without altering Emax. A similar and stronger effect was found in isolated guinea pig atria incubated under same conditions with MTX, except that 10(-4) M exposed for 150 min. was able to depress the Emax to isoproterenol by 21.2%. In addition, MTX (10(-4) M) in this model promoted a non-competitive antagonistic effect on the chronotropic action of histamine. These data are compatible with the idea that MTX could induce cardiac acute effects qualitatively similar to but of lower potency than those produced by doxorubicin in these two models. In addition, guinea pig atria seemed to display higher sensitivity to MTX compared to rat atrial preparations.

Effects of calcium channel entry blockers on cocaine and amphetamine-induced motor activities and toxicities

The effects of calcium channel entry blockers on cocaine and amphetamine-induced behavioral responses were investigated. Cocaine and amphetamine produced dose-dependent increases in locomotor activity and stereotyped behavior with a maximum response at 40 and 1.2 mg/kg, respectively. The 1,4-dihydropyridine nimodipine and the benzothiazepine diltiazem were more effective in inhibiting cocaine (20 mg/kg)-induced responses than amphetamine (0.6 mg/kg)-induced responses. At doses of cocaine and amphetamine that caused seizures and death, nimodipine, nitrendipine and diltiazem did not offer any protection; rather, they potentiated the toxicities produced by these psychomotor stimulants.