Effect of calcium to reverse the electrocardiographic effects of hyperkalemia in the isolated rat heart: a prospective, dose-response study

OBJECTIVES

To determine: a) any heart site or tissue-specific differences in the response to increased perfusion potassium concentrations, and b) the cellular site (intracellular vs. extracellular) of the effect of calcium on reversing electrocardiographic effects of hyperkalemia.

DESIGN

In vitro prospective, repeated-measures, dose-response study.

SETTING

University/medical school experimental physiology laboratory.

SUBJECTS

Adult male Sprague-Dawley rats whose hearts were studied in an in vitro perfusion preparation.

INTERVENTIONS

One group of hearts was perfused with modified Krebs-Henseleit physiologic salt solution onto which were superimposed infusions of concentrated potassium and/or calcium solutions. Infusion rates increased stepwise the respective ions in order to calculate increased concentrations through the course of the experiment. Calcium concentration was at either 4.0 or 5.4 mEq/L (2.0 or 2.7 mmol/L); potassium concentration was increased from 5.8 to 7.3, 8.0, 8.8, 10.2 and 11.8 mmol/L. Two more groups of hearts were perfused with Krebs-Henseleit solution containing the lower calcium concentration to which was added the calcium ionophore A23187 in one of two doses. A fourth group of hearts was perfused with Krebs-Henseleit solution containing the higher calcium concentration to which was added the a single dose of the calcium-channel blocking agent verapamil.

MEASUREMENTS AND MAIN RESULTS

We tested the effects of a series of ion and drug concentrations on epicardial EKG variables (atrial and ventricular rates, P-wave amplitude, PR interval, QRS complex amplitude and duration, and T-wave amplitude and duration). The effects of these variables were tested by increasing the ionized calcium in the perfusate of isolated rat hearts from 4.0 mEq/L (2.0 mmol/L) to 5.4 mEq/L (2.7 mmol/L) as perfusate potassium was increased stepwise from normal (5.8 mEq/L or mmol/L) to as high as 11.8 mEq/L (mmol/L). In addition, we studied the effect of adding the calcium ionophore A23187 to the perfusate with the lower ionized calcium concentration, and we also studied the effect of adding the calcium-channel blocking agent verapamil to the perfusate containing the higher ionized calcium while increasing the perfusate potassium concentration in a stepwise manner in each of the series. The higher calcium concentration (5.4 mEq/L or 2.7 mmol/L) prevented most of the adverse effects of the highest potassium concentration in the first drug-free series of experiments. When the calcium ionophore A23187 was added to the perfusate, most electrocardiographic variables remained normal even in the presence of a lower ionized calcium concentration. However, the higher ionized calcium concentration was not able to prevent electrical abnormalities in hearts perfused with high potassium when verapamil was in the solution.

CONCLUSIONS

We conclude that the mechanism whereby calcium reverses the clinically observable electrocardiographic effects of hyperkalemia is an intracellular one.

Age-related changes in body fluid volumes in young spontaneously hypertensive rats

We have measured total body water (TBW, by dessiccation), extracellular fluid volume (ECF, Na2(35)SO4 space), and plasma volume (PV, radioiodinated serum albumin space) in 5-sec-butyl-5-ethyl-2-thiobarbituric acid and sodium salt (Inactin)-anesthetized spontaneously hypertensive (SHR) and Wistar-Kyoto (WKY) rats aged 12-60 days. Interstitial fluid volume (ISF) was calculated as ECF minus PV. Changes in TBW, ECF, and ISF were largely a function of age in both strains, which is typical of developing mammals. Further analysis revealed that although these volumes were significantly larger in SHR before 25 days of age, after 30 days no difference existed between the strains. Before 25 days of age, when SHR's TBW was expanded, no weight difference was seen between the strains. However, once TBW was normalized (after 30 days), WKY was significantly heavier than SHR. The ISF volume was preferentially enlarged in SHR, although PV was also periodically greater. ISF normalized at the time when blood pressure becomes significantly higher in SHR, when (as we have previously reported) plasma aldosterone falls to WKY values in SHR and when renal function is approaching adult levels. Thus the return of ECF (ISF) to normal values may be a result of decreased aldosterone-dependent volume retention or to diuresis induced by increasing blood pressure in an animal whose renal function is close to maturity.

Use of power spectral analysis of respiratory sinus arrhythmia to detect graft rejection

Some evidence has suggested that graft rejection in heart transplant recipients is accompanied by sinus node dysfunction. To test this hypothesis the electrocardiograms of 21 orthotopic heart transplant recipients receiving cyclosporine were recorded at regularly scheduled biopsies. This resulted in 105 good quality recordings of at least 10 minutes each. All exhibited normal sinus rhythm. These recordings were then processed through patented digital routines that calculated the power spectrum of the RR intervals. All recordings exhibited Mayer wave and respiratory sinus arrhythmia (RSA) periodicities. Peak spectral power of RSA (PSP-RSA) demonstrated good repeatability at 2 weeks (r = 0.81). A paired t test comparing the baseline PSP-RSA in eight subjects who experienced rejection episodes with their individual average PSP-RSA during periods of rejection revealed a significant decrease (p = 0.039). As a global measure, PSP-RSA greater than 1 (natural logarithmic scales) demonstrated a sensitivity of 1.0, specificity of 0.42, positive predictive value of 0.22, and negative predictive value of 1.0. These tentative results demonstrate that PSP-RSA may be a sensitive, noninvasive marker for graft rejection of heart transplant patients receiving cyclosporine for immunosuppression. A larger, more extensive study needs to be conducted to confirm these results.

The role of arterial mineralocorticoid receptors in the mechanism of hypertension: findings and hypothesis

Alterations in electrolyte transport across cell membrane of vascular smooth muscle (VSM) and changes in hemodynamics [increased extracellular fluid volume (ECFV) and cardiac output (C.O.)] have been implicated in the pathogenetic mechanisms of both mineralocorticoid-induced hypertension (MH) and essential hypertension (EH). We have previously found that mineralocorticoids (MC) can act directly on arterial wall by means of a receptor-mediated mechanism, and have postulated that this mechanism is of critical importance in the increased reactivity of VSM to vasoconstrictive stimuli in MH. We now present evidence that a MC-antagonist at the MC-receptor level, progesterone, prevents induction of changes in VSM cell-membrane permeability to Na+ by MC, and development of hypertension. This study has been carried out on rabbits made hypertensive by s.c. implantation of silastic rubber strips impregnated with 11-desoxycorticosterone (the inducer) and/or 50 times that amount of progesterone (the anti-inducer). We hypothesize that the VSM cell-membrane defect (MC-induced in MH and congenital in EH) initiates two separate sequences of biochemical events. One leads, in early stages of hypertension, to expansion of ECFV, increase in C.O., myogenic vasoconstriction and hypertension. When kidney function matures, hypertension recedes. The second sequence of events leads to hypertension via an increase in [Na]i of VSM, leading to an increase in [Ca]i, and an increased contractility of VSM. This hypertension persists. The two sequences are concomitant but independent of each other.

Is there a common link between the mechanisms of mineralocorticoid-induced and genetic hypertension?

We have shown that (1) mineralocorticoids increase vascular smooth muscle (VSM) membrane permeability to Na+ through a receptor-mediated mechanism as mineralocorticoid-induced hypertension develops, and (2) prehypertensive spontaneously hypertensive rats (SHR) have elevated plasma aldosterone and expanded interstitial fluid volumes, both of which normalize as the rats reach the early hypertensive phase. Others have reported elevation in other mineralocorticoids, VSM membrane permeability changes to Na+ and exaggerated adrenocorticotrophic hormone (ACTH) response to stress in SHR. We hypothesize the SHR have a genetically determined, generalized membrane defect of increased Na+ permeability, not unlike that which is inducible by excessive exogenous mineralocorticoid and which accompanies the hypertension induced by mineralocorticoids. Further, we hypothesize that the insidious onset of hypertension in SHR is at least partly due to the absence or the low activity of Na/Ca exchange in VSM of young SHR, delaying the intracellular accumulation of Ca2+ with its consequent increase in VSM tension. Finally, we predict that the anticipated haemodynamic changes accompanying interstitial fluid volume expansion are not necessary to the development in SHR.