RÉSUMÉ
The Hatter Cardiovascular Institute biennial workshop, originally scheduled for April 2020 but postponed for 2 years due to the Covid pandemic, was organised to debate and discuss the future of Remote Ischaemic Conditioning (RIC). This evolved from the large multicentre CONDI-2-ERIC-PPCI outcome study which demonstrated no additional benefit when using RIC in the setting of ST-elevation myocardial infarction (STEMI). The workshop discussed how conditioning has led to a significant and fundamental understanding of the mechanisms preventing cell death following ischaemia and reperfusion, and the key target cyto-protective pathways recruited by protective interventions, such as RIC. However, the obvious need to translate this protection to the clinical setting has not materialised largely due to the disconnect between preclinical and clinical studies. Discussion points included how to adapt preclinical animal studies to mirror the patient presenting with an acute myocardial infarction, as well as how to refine patient selection in clinical studies to account for co-morbidities and ongoing therapy. These latter scenarios can modify cytoprotective signalling and need to be taken into account to allow for a more robust outcome when powered appropriately. The workshop also discussed the potential for RIC in other disease settings including ischaemic stroke, cardio-oncology and COVID-19. The workshop, therefore, put forward specific classifications which could help identify so-called responders vs. non-responders in both the preclinical and clinical settings.
Sujet(s)
Encéphalopathie ischémique , COVID-19 , Préconditionnement ischémique myocardique , Accident vasculaire cérébral , Animaux , Éducation , Ischémie , Résultat thérapeutiqueRÉSUMÉ
We aimed to identify factors influencing the sensitivity of perfusion imaging after an initial positive coronary computed tomography angiography (CCTA) using invasive coronary angiography (ICA) with conditional fractional flow reserve (FFR) as reference. Secondly we aimed to identify factors associated with revascularisation and to evaluate treatment outcome after ICA. We analysed 292 consecutive patients with suspected significant coronary artery disease (CAD) at CCTA, who underwent perfusion imaging with either cardiac magnetic resonance (CMR) or myocardial perfusion scintigraphy (MPS) followed by ICA with conditional FFR. Stratified analysis and uni- and multiple logistic regression analyses were performed to identify predictors of diagnostic agreement between perfusion scans and ICA and predictors of revascularisation. Myocardial ischemia evaluated with perfusion scans was present in 65/292 (22%) while 117/292 (40%) had obstructive CAD evaluated by ICA. Revascularisation rate was 90/292 (31%). The overall sensitivity for perfusion scans was 39% (30-48), specificity 89% (83-93), PPV 69% (57-80) and NPV 68% (62-74). Stratified analysis showed higher sensitivities in patients with multi-vessel disease at CCTA 49% (37-60) and typical chest pain 50% (37-60). Predictors of revascularisation were multi-vessel disease by CCTA (OR 3.51 [1.91-6.48]) and a positive perfusion scan (OR 4.69 [2.49-8.83]). The sensitivity for perfusion scans after CCTA was highest in patients with typical angina and multiple lesions at CCTA and predicted diagnostic agreement between perfusion scans and ICA. Abnormal perfusion and multi vessel disease at CCTA predicted revascularisation.
Sujet(s)
Angiographie par tomodensitométrie , Coronarographie/méthodes , Maladie des artères coronaires/imagerie diagnostique , Vaisseaux coronaires/imagerie diagnostique , Fraction du flux de réserve coronaire , Imagerie par résonance magnétique , Imagerie de perfusion myocardique/méthodes , Scintigraphie/méthodes , Sujet âgé , Maladie des artères coronaires/physiopathologie , Maladie des artères coronaires/chirurgie , Vaisseaux coronaires/physiopathologie , Vaisseaux coronaires/chirurgie , Danemark , Femelle , Humains , Mâle , Adulte d'âge moyen , Revascularisation myocardique , Valeur prédictive des tests , Reproductibilité des résultats , Indice de gravité de la maladie , Résultat thérapeutiqueRÉSUMÉ
Hepatic and renal energy status prior to transplantation correlates with graft survival. However, effects of brain death (BD) on organ-specific energy status are largely unknown. We studied metabolism, perfusion, oxygen consumption, and mitochondrial function in the liver and kidneys following BD. BD was induced in mechanically-ventilated rats, inflating an epidurally-placed Fogarty-catheter, with sham-operated rats as controls. A 9.4T-preclinical MRI system measured hourly oxygen availability (BOLD-related R2*) and perfusion (T1-weighted). After 4 hrs, tissue was collected, mitochondria isolated and assessed with high-resolution respirometry. Quantitative proteomics, qPCR, and biochemistry was performed on stored tissue/plasma. Following BD, the liver increased glycolytic gene expression (Pfk-1) with decreased glycogen stores, while the kidneys increased anaerobic- (Ldha) and decreased gluconeogenic-related gene expression (Pck-1). Hepatic oxygen consumption increased, while renal perfusion decreased. ATP levels dropped in both organs while mitochondrial respiration and complex I/ATP synthase activity were unaffected. In conclusion, the liver responds to increased metabolic demands during BD, enhancing aerobic metabolism with functional mitochondria. The kidneys shift towards anaerobic energy production while renal perfusion decreases. Our findings highlight the need for an organ-specific approach to assess and optimise graft quality prior to transplantation, to optimise hepatic metabolic conditions and improve renal perfusion while supporting cellular detoxification.
Sujet(s)
Adaptation physiologique , Mort cérébrale/métabolisme , Métabolisme énergétique , Animaux , Marqueurs biologiques , Expression des gènes , Rein/métabolisme , Foie/métabolisme , Mâle , Mitochondries/métabolisme , Spécificité d'organe , Stress oxydatif , Consommation d'oxygène , Perfusion , RatsRÉSUMÉ
Aims: Perfusion scans after coronary computed tomography angiography (CCTA) in patients with suspected coronary artery disease (CAD) may reduce unnecessary invasive coronary angiographies (ICAs). However, the diagnostic accuracy of perfusion scans after primary CCTA is unknown. The aim of this study was to determine the diagnostic accuracy of cardiac magnetic resonance (CMR) and myocardial perfusion scintigraphy (MPS) against ICA with fractional flow reserve (FFR) in patients suspected of CAD by CCTA. Methods and results: Included were consecutive patients (1675) referred to CCTA with symptoms of CAD and low/intermediate risk profile. Patients with suspected CAD based on CCTA were randomized 1:1 to CMR or MPS followed by ICA with FFR. Obstructive CAD was defined as FFR ≤ 0.80 or > 90% diameter stenosis by visual assessment. After initial CCTA, 392 patients (23%) were randomized; 197 to CMR and 195 to MPS. Perfusion scans and ICA were completed in 292 patients (CMR 148, MPS 144). Based on the ICA, 117/292 (40%) patients were classified with CAD. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for CMR were 41%, 95% CI [28-54], 84% [75-91], 62% [45-78], and 68% [58-76], respectively. For the MPS group 36% [24-50], 94% [87-98], 81% [61-93], and 68% [59-76], respectively. Conclusion: Patients with low/intermediate CAD risk and a positive CCTA scan represent a challenge to perfusion techniques indicated by the low sensitivity of both CMR and MPS with FFR as a reference. The mechanisms underlying this discrepancy need further investigation.
Sujet(s)
Angiographie par tomodensitométrie/méthodes , Coronarographie/méthodes , Maladie des artères coronaires/imagerie diagnostique , IRM dynamique/méthodes , Imagerie de perfusion myocardique/méthodes , Sujet âgé , Maladie des artères coronaires/physiopathologie , Femelle , Fraction du flux de réserve coronaire/physiologie , Humains , Mâle , Adulte d'âge moyen , Valeur prédictive des tests , Sensibilité et spécificitéRÉSUMÉ
In the 30 years since the original description of ischaemic preconditioning, understanding of the pathophysiology of ischaemia/reperfusion injury and concepts of cardioprotection have been revolutionised. In the same period of time, management of patients with coronary artery disease has also been transformed: coronary artery and valve surgery are now deemed routine with generally excellent outcomes, and the management of acute coronary syndromes has seen decade on decade reductions in cardiovascular mortality. Nonetheless, despite these improvements, cardiovascular disease and ischaemic heart disease in particular, remain the leading cause of death and a significant cause of long-term morbidity (with a concomitant increase in the incidence of heart failure) worldwide. The need for effective cardioprotective strategies has never been so pressing. However, despite unequivocal evidence of the existence of ischaemia/reperfusion in animal models providing a robust rationale for study in man, recent phase 3 clinical trials studying a variety of cardioprotective strategies in cardiac surgery and acute ST-elevation myocardial infarction have provided mixed results. The investigators meeting at the Hatter Cardiovascular Institute workshop describe the challenge of translating strong pre-clinical data into effective clinical intervention strategies in patients in whom effective medical therapy is already altering the pathophysiology of ischaemia/reperfusion injury-and lay out a clearly defined framework for future basic and clinical research to improve the chances of successful translation of strong pre-clinical interventions in man.
Sujet(s)
Lésion de reperfusion myocardique , , Animaux , Humains , Préconditionnement ischémique myocardique/méthodes , Préconditionnement ischémique myocardique/tendancesRÉSUMÉ
Patients with chronic kidney disease (CKD) frequently require radiographic examinations. We investigated the impact of repeated contrast administrations on short- and long-term kidney function and mortality in kidney transplantation candidates. In a prospective study, 81 predialysis transplantation candidates underwent computed tomography angiography (CTA) and invasive coronary angiography (ICA) as part of a pretransplant cardiovascular evaluation. Postcontrast plasma creatinine (P-creatinine) changes were compared with a precontrast control period. We identified postcontrast acute kidney injury (AKI) in 10 patients (13%) after CTA and in two patients (3%) after ICA. Compared with the control period, relative changes in P-creatinine were significantly higher after CTA (p < 0.001) and ICA (p < 0.01). Diabetic kidney failure (p < 0.05) and contrast dose >0.8 mL/kg (p < 0.001) were associated with increases in P-creatinine. All cases of postcontrast AKI were reversible, and we found no differences between the progression rates of the kidney failure during 12 months before and after contrast exposure (p = 0.56). In a Cox regression analysis, creatinine changes after CTA or ICA were not associated with increased need for dialysis treatment or mortality. Contrast exposure and transient postcontrast AKI did not increase the risk of accelerated CKD progression or the time to initiation of dialysis or death.
Sujet(s)
Atteinte rénale aigüe/étiologie , Produits de contraste/effets indésirables , Défaillance rénale chronique/complications , Transplantation rénale/effets indésirables , Complications postopératoires , Adulte , Sujet âgé , Produits de contraste/administration et posologie , Coronarographie/méthodes , Créatinine/sang , Femelle , Études de suivi , Débit de filtration glomérulaire , Rejet du greffon , Survie du greffon , Humains , Défaillance rénale chronique/imagerie diagnostique , Défaillance rénale chronique/chirurgie , Tests de la fonction rénale , Mâle , Adulte d'âge moyen , Pronostic , Études prospectives , Facteurs de risque , Indice de gravité de la maladie , Tomodensitométrie/méthodesRÉSUMÉ
Early initiation of everolimus with calcineurin inhibitor therapy has been shown to reduce the progression of cardiac allograft vasculopathy (CAV) in de novo heart transplant recipients. The effect of de novo everolimus therapy and early total elimination of calcineurin inhibitor therapy has, however, not been investigated and is relevant given the morbidity and lack of efficacy of current protocols in preventing CAV. This 12-month multicenter Scandinavian trial randomized 115 de novo heart transplant recipients to everolimus with complete calcineurin inhibitor elimination 7-11 weeks after HTx or standard cyclosporine immunosuppression. Ninety-five (83%) patients had matched intravascular ultrasound examinations at baseline and 12 months. Mean (± SD) recipient age was 49.9 ± 13.1 years. The everolimus group (n = 47) demonstrated significantly reduced CAV progression as compared to the calcineurin inhibitor group (n = 48) (ΔMaximal Intimal Thickness 0.03 ± 0.06 and 0.08 ± 0.12 mm, ΔPercent Atheroma Volume 1.3 ± 2.3 and 4.2 ± 5.0%, ΔTotal Atheroma Volume 1.1 ± 19.2 mm(3) and 13.8 ± 28.0 mm(3) [all p-values ≤ 0.01]). Everolimus patients also had a significantly greater decline in levels of soluble tumor necrosis factor receptor-1 as compared to the calcineurin inhibitor group (p = 0.02). These preliminary results suggest that an everolimus-based CNI-free can potentially be considered in suitable de novo HTx recipients.
Sujet(s)
Inhibiteurs de la calcineurine/usage thérapeutique , Évérolimus/usage thérapeutique , Rejet du greffon/prévention et contrôle , Cardiopathies/chirurgie , Transplantation cardiaque , Receveurs de transplantation , Maladies vasculaires/traitement médicamenteux , Adulte , Allogreffes , Ciclosporine/usage thérapeutique , Association de médicaments , Femelle , Études de suivi , Rejet du greffon/diagnostic , Rejet du greffon/étiologie , Survie du greffon , Cardiopathies/complications , Humains , Immunosuppresseurs/usage thérapeutique , Mâle , Adulte d'âge moyen , Complications postopératoires , Pronostic , Facteurs de risque , Sirolimus/usage thérapeutique , Maladies vasculaires/diagnostic , Maladies vasculaires/étiologieRÉSUMÉ
BACKGROUND AND AIM: The prognostic impact of ACE inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) on stroke mortality remains unclear. We aimed to examine whether prestroke use of ACE-Is or ARBs was associated with improved short-term mortality following ischaemic stroke, intracerebral haemorrhage (ICH) and subarachnoid haemorrhage (SAH). METHODS: We conducted a nationwide population-based cohort study using medical registries in Denmark. We identified all first-time stroke patients during 2004-2012 and their comorbidities. We defined ACE-I/ARB use as current use (last prescription redemption <90â days before admission for stroke), former use and non-use. Current use was further classified as new or long-term use. We used Cox regression modelling to compute 30-day mortality rate ratios (MRRs) with 95% CIs, controlling for potential confounders. RESULTS: We identified 100â 043 patients with a first-time stroke. Of these, 83â 736 patients had ischaemic stroke, 11â 779 had ICH, and 4528 had SAH. For ischaemic stroke, the adjusted 30-day MRR was reduced in current users compared with non-users (0.85, 95% CI 0.81 to 0.89). There was no reduction in the adjusted 30-day MRR for ICH (0.95, 95% CI 0.87 to 1.03) or SAH (1.01, 95% CI 0.84 to 1.21), comparing current users with non-users. No association with mortality was found among former users compared with non-users. No notable modification of the association was observed within sex or age strata. CONCLUSIONS: Current use of ACE-Is/ARBs was associated with reduced 30-day mortality among patients with ischaemic stroke. We found no association among patients with ICH or SAH.
Sujet(s)
Antagonistes des récepteurs aux angiotensines/usage thérapeutique , Inhibiteurs de l'enzyme de conversion de l'angiotensine/usage thérapeutique , Accident vasculaire cérébral/mortalité , Sujet âgé , Sujet âgé de 80 ans ou plus , Encéphalopathie ischémique/mortalité , Hémorragie cérébrale/mortalité , Études de cohortes , Danemark/épidémiologie , Femelle , Humains , Hypertension artérielle/traitement médicamenteux , Mâle , Adulte d'âge moyen , Enregistrements , Facteurs de risque , Hémorragie meningée/mortalitéRÉSUMÉ
BACKGROUND: Intravenous administration of alteplase is the only approved treatment for acute ischemic stroke. Despite the effectiveness of this treatment, 50% of patients suffer chronic neurological disability, which may in part be caused by ischemia-reperfusion injury. Remote ischemic perconditioning, performed as a transient ischemic stimulus by blood-pressure cuff inflation to an extremity, has proven effective in attenuating ischemia-reperfusion injury in animal models of stroke. Remote ischemic perconditioning increases myocardial salvage in patients undergoing acute revascularization for acute myocardial infarction. To clarify whether a similar benefit can be obtained in patients undergoing thrombolysis for acute stroke, we included patients from June 2009 to January 2011. AIM AND DESIGN: The aims of the study are: to estimate the effect of remote ischemic perconditioning as adjunctive therapy to intravenous alteplase of acute ischemic stroke within the 4-h time window and to investigate the feasibility of remote ischemic perconditioning performed during transport to hospital in patients displaying symptoms of acute stroke. Patients are randomized to remote ischemic perconditioning in a single-blinded fashion during transportation to hospital. Only patients with magnetic resonance imaging-proven ischemic stroke, who subsequently are treated with intravenous alteplase, and in selected cases additional endovascular treatment, are finally included in the study. STUDY OUTCOMES: Primary end-point is penumbral salvage. Penumbra is defined as hypoperfused yet viable tissue identified as the mismatch between perfusion-weighted imaging and diffusion-weighted imaging lesion on magnetic resonance imaging scans. Primary outcome is a mismatch volume not progressing to infarction on one-month follow-up T2 fluid attenuated inversion recovery. Secondary end-points include: infarct growth (expansion of the diffusion-weighted imaging lesion) from baseline to the 24-h and one-month follow-up examination. Infarct growth inside and outside the acute perfusion-weighted imaging-diffusion-weighted imaging mismatch zone is quantified by use of coregistration. Clinical outcome after three-months. The influence of physical activity (Physical Activity Scale for the Elderly score) on effect of remote ischemic perconditioning. Feasibility of remote ischemic perconditioning in acute stroke patients. SUMMARY: This phase 3 trial is the first study in patients with acute ischemic stroke to evaluate the effect size of remote ischemic perconditioning as a pretreatment to intravenous alteplase, measured as penumbral salvage on multimodal magnetic resonance imaging and clinical outcome after three-months follow-up.
Sujet(s)
Encéphalopathie ischémique/traitement médicamenteux , Neuroprotecteurs/administration et posologie , Accident vasculaire cérébral/traitement médicamenteux , Traitement thrombolytique/méthodes , Encéphalopathie ischémique/complications , Imagerie par résonance magnétique de diffusion/méthodes , Études de faisabilité , Fibrinolytiques/usage thérapeutique , Études de suivi , Humains , Perfusions veineuses , Plan de recherche , Méthode en simple aveugle , Accident vasculaire cérébral/complications , Facteurs temps , Activateur tissulaire du plasminogène/usage thérapeutique , Résultat thérapeutiqueRÉSUMÉ
INTRODUCTION: Neonates undergoing congenital heart surgery frequently need post-operative inotropic support. Knowledge about the effect of inotropes on myocardial metabolism in the newborn heart is limited, and the choice of inotropic therapy is based mainly on evidence from studies in adults. The aim of this study was to compare the effect of three inotropic strategies on the myocardial metabolism in a neonatal pig model. METHODS: Newborn piglets were randomised to intravenous infusions with: adrenaline and milrinone; dopamine and milrinone; dobutamine in haemodynamically equivalent doses; or isotonic saline, through 3 h. Microdialysis catheters were inserted in the myocardium of the left and right ventricle, and concentrations of lactate, pyruvate, glycerol, and glucose were measured in the microdialysate. In myocardial biopsies, tissue lactate and intracellular glycogen concentrations were determined, and arterial blood samples were analysed for lactate and glucose. RESULTS: No statistically significant differences were observed in haemodynamics between the three interventions. Metabolic variables demonstrated a consistent increase in lactate concentration in blood, myocardial dialysate, and biopsies in milrinone-adrenaline-treated animals. The lactate concentration remained stable in all other groups in all samples. The myocardial lactate/pyruvate ratio did not increase and was not significantly different between groups. CONCLUSION: Milrinone and adrenaline induced significantly higher lactate levels in neonatal piglets. The increase was not caused by myocardial ischaemia, but rather due to a beta-stimulation-induced glycolysis.
Sujet(s)
Cardiotoniques/administration et posologie , Myocarde/métabolisme , Animaux , Animaux nouveau-nés , Dobutamine/administration et posologie , Dopamine/pharmacologie , Épinéphrine/administration et posologie , Hémodynamique/effets des médicaments et des substances chimiques , Acide lactique/métabolisme , Microdialyse , Milrinone/administration et posologie , Acide pyruvique/métabolisme , SuidaeRÉSUMÉ
In this 12-month multicenter Scandinavian study, 78 maintenance heart transplant (HTx) recipients randomized to everolimus with reduced calcineurin inhibitor (CNI) exposure or continued standard CNI-therapy underwent matched virtual histology (VH) examination to evaluate morphological progression of cardiac allograft vasculopathy (CAV). Parallel measurement of a range of inflammatory markers was also performed. A similar rate of quantitative CAV progression was observed in the everolimus (n = 30) and standard CNI group (n = 48) (plaque index 1.9 ± 3.8% and 1.6 ± 3.9%, respectively; p = 0.65). However, VH analysis revealed a significant increase in calcified (2.4 ± 4.0 vs. 0.3 ± 3.1%; p = 0.02) and necrotic component (6.5 ± 8.5 vs. 1.1 ± 8.6%; p = 0.01) among everolimus patients compared to controls. The increase in necrotic and calcified components was most prominent in everolimus patients with time since HTx >5.1 years and was accompanied by a significant increase in levels of von Willebrand (vWF) factor (p = 0.04) and vascular cell adhesion molecule (VCAM) (p = 0.03). Conversion to everolimus and reduced CNI is associated with a significant increase in calcified and necrotic intimal components and is more prominent in patients with a longer time since HTx. A significant increase in vWF and VCAM accompanied these qualitative changes and the prognostic implication of these findings requires further investigation.
Sujet(s)
Transplantation cardiaque/effets indésirables , Immunosuppresseurs/usage thérapeutique , Sirolimus/analogues et dérivés , Maladies vasculaires/étiologie , Adulte , Sujet âgé , Études cas-témoins , Évérolimus , Femelle , Humains , Mâle , Adulte d'âge moyen , Sirolimus/usage thérapeutiqueRÉSUMÉ
CONTEXT: Glucagon-like peptide-1 (GLP-1) and GLP-1 receptor agonists provide beneficial cardiovascular effects by protecting against ischemia and reperfusion injury. Type 2 diabetes mellitus patients have reduced glycolysis in the heart. OBJECTIVE: We hypothesized that cardioprotection by GLP-1 is achieved through increased glucose availability and utilization and aimed to assess the effect of exenatide, a synthetic GLP-1 receptor agonist, on myocardial glucose uptake (MGU), myocardial glucose transport, and myocardial blood flow (MBF). DESIGN AND METHODS: We conducted a randomized, double-blinded, placebo-controlled crossover study in eight male, insulin-naive, type 2 diabetes mellitus patients without coronary artery disease. Positron emission tomography was used to determine the effect of exenatide on MGU and MBF during a pituitary-pancreatic hyperglycemic clamp with (18)F-fluorodeoxyglucose and (13)N-ammonia as tracers. RESULTS: Overall, exenatide did not alter MGU. However, regression analysis revealed that exenatide altered initial clearance of glucose over the membrane of cardiomyocytes and MGU, depending on the level of insulin resistance (P = 0.017 and 0.010, respectively). Exenatide increased MBF from 0.73 ± 0.094 to 0.85 ± 0.091 ml/g · min (P = 0.0056). Except for an increase in C-peptide levels, no differences in circulating hormones or metabolites were found. CONCLUSIONS: The action of exenatide as an activator or inhibitor of the glucose transport and glucose uptake in cardiomyocytes is dependent on baseline activity of glucose transport and insulin resistance. Exenatide increases MBF without changing MGU.
Sujet(s)
Circulation coronarienne/effets des médicaments et des substances chimiques , Diabète de type 2/métabolisme , Diabète de type 2/physiopathologie , Glucose/pharmacocinétique , Insulinorésistance/physiologie , Myocarde/métabolisme , Peptides/pharmacologie , Venins/pharmacologie , Transport biologique/effets des médicaments et des substances chimiques , Transport biologique/physiologie , Études croisées , Diabète de type 2/imagerie diagnostique , Diabète de type 2/anatomopathologie , Méthode en double aveugle , Exénatide , Glucose/métabolisme , Coeur/effets des médicaments et des substances chimiques , Humains , Hypoglycémiants/pharmacologie , Mâle , Adulte d'âge moyen , Myocarde/anatomopathologie , Placebo , Tomographie par émission de positons , Débit sanguin régional/effets des médicaments et des substances chimiques , Régulation positive/effets des médicaments et des substances chimiquesRÉSUMÉ
Exercise protects against myocardial ischemia-reperfusion (I-R) injury but the mechanism remains unclear. Protection can be transferred from a remotely preconditioned human donor to an isolated perfused rabbit heart using a dialysate of plasma. We hypothesized that physical exercise preconditioning also confers cardioprotection through a humorally mediated effector dependent on opioid receptor activation. Thirteen male volunteers performed vigorous exercise (four 2-minute bouts of high-intensity exercise) and 1 week later they underwent remote ischemic preconditioning (four cycles of 5 min upper limb ischemia and reperfusion). Dialysates were prepared from blood collected before (control) and after the two interventions. Isolated rabbit hearts were perfused with the dialysates without and with co-administration of naloxone (opioid receptor antagonist) prior to 40 min regional ischemia and 2 h reperfusion. Exercise and remote ischemic preconditioning (rIPC) reduced infarct size from 60 ± 5 to 35 ± 5 % and from 57 ± 7 to 27 ± 3 % of the area at risk, respectively (p < 0.05 and < 0.01). Furthermore, post-ischemic left ventricular developed pressure was improved compared with controls (p = 0.08 for exercise and p = 0.04 for rIPC). Co-perfusion with naloxone abrogated the protective effects of exercise and remote ischemic preconditioned dialysates. In conclusion, high-intensity exercise preconditioning elicits cardioprotection through a humorally mediated dependent on opioid receptor activation, similar to rIPC.
Sujet(s)
Transfusion sanguine , Exercice physique , Préconditionnement ischémique/méthodes , Infarctus du myocarde/prévention et contrôle , Lésion de reperfusion myocardique/prévention et contrôle , Communication paracrine , Membre supérieur/vascularisation , Adolescent , Adulte , Animaux , Hémodynamique , Humains , Techniques in vitro , Acide lactique/métabolisme , Mâle , Infarctus du myocarde/sang , Infarctus du myocarde/anatomopathologie , Infarctus du myocarde/physiopathologie , Lésion de reperfusion myocardique/sang , Lésion de reperfusion myocardique/anatomopathologie , Lésion de reperfusion myocardique/physiopathologie , Myocarde/métabolisme , Myocarde/anatomopathologie , Naloxone/pharmacologie , Antagonistes narcotiques/pharmacologie , Communication paracrine/effets des médicaments et des substances chimiques , Lapins , Facteurs temps , Fonction ventriculaire gauche , Pression ventriculaire , Jeune adulteRÉSUMÉ
BACKGROUND: Cytochrome P450 inhibition by proton pump inhibitors (PPIs) may attenuate the effectiveness of clopidogrel. AIM: To examine whether PPI use modifies the association between clopidogrel use and major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI) with stent implantation, using time-varying drug exposure ascertainment. METHODS: We conducted this population-based cohort study in Western Denmark (population 3 million) using medical databases. We identified all 13,001 patients with coronary stent implantation between 2002 and 2005 and ascertained their reported comorbidities. During the recommended 12-month postintervention treatment period, we tracked use of clopidogrel and PPI and the rate of MACE. We used Cox regression to compute hazard ratios (HRs), controlling for potential confounders. RESULTS: During follow-up, one or more prescriptions were redeemed by 91% of patients for clopidogrel and by 21% of patients for PPIs. Of the patients, 15% experienced a MACE. The adjusted HR for MACE comparing clopidogrel use with non-use was 0.57 [95% confidence interval (CI): 0.44-0.74] among PPI users and 0.47 (95% CI: 0.42-0.53) among PPI non-users, yielding an interaction effect (i.e. relative rate increase) of 1.20 (95% CI: 0.91-1.58). PPI users treated from before PCI had a 25% increased rate of MACE compared to PPI non-users, independent of clopidogrel use [adjusted HR = 1.24 (95% CI: 0.97-1.58) for clopidogrel users and 1.26 (95% CI: 0.97-1.63) for clopidogrel non-users]. CONCLUSIONS: The use of PPIs as a class did not modify the protective effect of clopidogrel, but its use was associated with major adverse cardiovascular events itself, particularly among patients having used PPIs before percutaneous coronary intervention.
Sujet(s)
Inhibiteurs des enzymes du cytochrome P-450 , Reflux gastro-oesophagien/traitement médicamenteux , Infarctus du myocarde/induit chimiquement , Antiagrégants plaquettaires/effets indésirables , Inhibiteurs de la pompe à protons/effets indésirables , Ticlopidine/analogues et dérivés , Adulte , Sujet âgé , Sujet âgé de 80 ans ou plus , Ablation par cathéter , Clopidogrel , Études de cohortes , Cytochrome P-450 enzyme system/effets indésirables , Interactions médicamenteuses , Association de médicaments , Femelle , Reflux gastro-oesophagien/diagnostic , Humains , Mâle , Adulte d'âge moyen , Infarctus du myocarde/chirurgie , Facteurs de risque , Endoprothèses , Ticlopidine/effets indésirablesRÉSUMÉ
The force-frequency relationship (FFR) reflects alterations in intracellular calcium cycling during changing heart rate (HR). Tachycardia-induced heart failure is associated with depletion of intracellular calcium. We hypothesized (1) that the relative resistance to tachycardia-induced heart failure seen in neonatal pigs is related to differences in calcium cycling, resulting in different FFR responses and (2) that pretreatment with digoxin to increase intracellular calcium would modifies these changes. LV +dP/dt was measured during incremental right atrial pacing in 16 neonatal and 14 adult pigs. FFR was measured as the change in +dP/dt as HR was increased. Animals were randomized to control or intravenous bolus digoxin (n = 8 neonate pigs in the 0.05 mg/kg group and n = 7 adult pigs in the 0.025 mg/kg group) and paced for 90 min at 25 bpm greater than the rate of peak +dP/dt. Repeat FFR was then obtained. The postpacing FFR in neonatal control pigs shifted rightward, with peak force occurring 30 bpm greater than baseline (P < 0.03). There was no vertical shift; thus, force at 150 bpm decreased (P < 0.03) and force at 300 beats/min increased (P < 0.08). In adult control pigs, FFR shifted downward (P < 0.01), with decreased force generation at all HRs. In both neonates and adult pigs, digoxin increased +dP/dt at all HRs; however, in neonate pigs digoxin decreased the contractile reserve by abrogation of the rightward shift of FFR. An adaptive response to tachycardia in the neonate pig leads to improved force generation at greater HRs. Conversely, the response of the mature pig heart is maladaptive with decreased force generation. Pretreatment with digoxin modifies these responses.
Sujet(s)
Animaux nouveau-nés , Rythme cardiaque/physiologie , Contraction myocardique/physiologie , Tachycardie/physiopathologie , Facteurs âges , Animaux , Canaux calciques/effets des médicaments et des substances chimiques , Canaux calciques/physiologie , Entraînement électrosystolique , Cardiotoniques/pharmacologie , Cytoplasme/effets des médicaments et des substances chimiques , Cytoplasme/métabolisme , Cytosol/effets des médicaments et des substances chimiques , Cytosol/métabolisme , Digoxine/pharmacologie , Électrocardiographie/effets des médicaments et des substances chimiques , Défaillance cardiaque/physiopathologie , Rythme cardiaque/effets des médicaments et des substances chimiques , Modèles théoriques , Contraction myocardique/effets des médicaments et des substances chimiques , Réticulum sarcoplasmique/effets des médicaments et des substances chimiques , Réticulum sarcoplasmique/physiologie , Suidae , Fonction ventriculaire gauche/effets des médicaments et des substances chimiques , Fonction ventriculaire gauche/physiologieRÉSUMÉ
AIMS/HYPOTHESIS: Sulfonylureas (SUs) may impair outcome in patients with acute coronary syndrome. Most experimental studies of the myocardial effects of SU treatment are performed in non-diabetic models. We compared the effect of two widely used SUs, glibenclamide (gb) and gliclazide (gc), with high and low myocardial K(ATP) channel affinity, respectively, at therapeutic concentrations on infarct size, left ventricular (LV) function and myocardial glycogen, lactate and alanine content before and after ischaemia/reperfusion (I/R). METHODS: Non-diabetic Wistar and diabetic Goto-Kakizaki rat hearts were investigated in a Langendorff preparation. Gb (0.1 µmol/l) and gc (1.0 µmol/l) were administrated throughout the study. Infarct size was evaluated after 120 min of reperfusion. Myocardial metabolite content was measured before and after ischaemia. RESULTS: Infarct size was smaller in diabetic hearts than in non-diabetic hearts (0.33 ± 0.03 vs 0.51 ± 0.05, p < 0.05). Gb increased infarct size (0.54 ± 0.04 vs 0.33 ± 0.03, p < 0.05) and reduced post-ischaemic LV developed pressure (60 ± 3 vs 76 ± 3 mmHg, p < 0.05) and coronary flow (4.9 ± 0.5 vs 7.1 ± 0.4 ml min(-1) g(-1), p < 0.05) in gb-treated diabetic rats compared with untreated diabetic rats. On comparing gb-treated diabetic rats with untreated diabetic rats, glycogen content was reduced before (9.1 ± 0.6 vs 13.6 ± 1.0 nmol/mg wet weight, p < 0.01) and after ischaemia (0.9 ± 0.2 vs 1.8 ± 0.2 nmol/mg wet weight, p < 0.05), and lactate (4.8 ± 0.4 vs 3.2 ± 0.3 nmol/mg wet weight, p < 0.01) and alanine (1.38 ± 0.12 vs 0.96 ± 0.09 nmol/mg wet weight, p < 0.05) contents were increased during reperfusion. Gc-treatment of diabetic and non-diabetic rats did not affect any of the measured variables. CONCLUSIONS/INTERPRETATIONS: Gb, but not gc, exacerbates I/R injury and deteriorates LV function in diabetic hearts. These effects of gb on diabetic hearts may be due to detrimental effects on myocardial carbohydrate metabolism.
Sujet(s)
Infarctus du myocarde/induit chimiquement , Myocarde/métabolisme , Canaux potassiques/effets des médicaments et des substances chimiques , Sulfonylurées/effets indésirables , Animaux , Diabète de type 2/traitement médicamenteux , Gliclazide/effets indésirables , Gliclazide/usage thérapeutique , Glibenclamide/effets indésirables , Glibenclamide/usage thérapeutique , Glycogène/métabolisme , Acide lactique/métabolisme , Mâle , Infarctus du myocarde/métabolisme , Rats , Rat Wistar , Sulfonylurées/usage thérapeutiqueRÉSUMÉ
1. Because diabetic hearts have an increased threshold for cardioprotection by ischaemic preconditioning (IPC), we hypothesized that protection by L-glutamate during reperfusion is restricted in Type 2 diabetic hearts. Previously, we found that L-glutamate-mediated postischaemic cardioprotection mimics IPC. 2. Rat hearts were studied in a Langendorff preparation perfused with Krebs'-Henseleit solution and subjected to 40 min global no-flow ischaemia, followed by 120 min reperfusion. L-Glutamate (0, 15 and 30 mmol/L) was added to the perfusate during reperfusion of hearts from non-diabetic (Wistar-Kyoto) and diabetic (Zucker diabetic fatty (ZDF)) rats, studied at 16 weeks of age. The infarct size (IS)/area-at-risk (AAR) ratio was the primary end-point. Expression of L-glutamate excitatory amino acid transporter (EAAT) 1 (mitochondrial) and EAAT3 (sarcolemmal) was determined by quantitative polymerase chain reaction and immunoblotting. 3. The ISS/AAR ratio did not differ between control hearts from Wistar-Kyoto and ZDF rats (0.52 ± 0.03 and 0.51 ± 0.04, respectively; P = 0.90). L-Glutamate (15 mmol/L) significantly reduced the IS/AAR ratio in non-diabetic hearts, but not in diabetic hearts, compared with their respective controls. The higher concentration of L-glutamate (30 mmol/L) reduced infarct size in diabetic hearts to the same degree as in non-diabetic hearts (IS/AAR 0.35 ± 0.03 (P = 0.002) and 0.34 ± 0.03 (P = 0.004), respectively). The mitochondrial L-glutamate transporter EAAT1 was downregulated in hearts from ZDF rats at both the mRNA and protein levels (P < 0.0005 and P < 0.0001, respectively). However, there was no change in EAAT3 expression at the protein level. Myocardial L-glutamate content was increased by 43% in diabetic hearts (P < 0.0001). 4. Hearts from obese diabetic rats have an elevated threshold for metabolic postischaemic cardioprotection by L-glutamate. These findings may reflect underlying mechanisms of inherent resistance against additional cardioprotection in the diabetic heart.
Sujet(s)
Cardiotoniques/pharmacologie , Complications du diabète/prévention et contrôle , Diabète de type 2/traitement médicamenteux , Acide glutamique/pharmacologie , Infarctus du myocarde/prévention et contrôle , Lésion de reperfusion myocardique/prévention et contrôle , Obésité/complications , Animaux , Technique de Western , Complications du diabète/étiologie , Complications du diabète/génétique , Complications du diabète/métabolisme , Complications du diabète/anatomopathologie , Complications du diabète/physiopathologie , Diabète de type 2/étiologie , Diabète de type 2/génétique , Diabète de type 2/métabolisme , Diabète de type 2/physiopathologie , Modèles animaux de maladie humaine , Relation dose-effet des médicaments , Transporteur-1 d'acides aminés excitateurs/génétique , Transporteur-1 d'acides aminés excitateurs/métabolisme , Transporteur-3 d'acides aminés excitateurs/génétique , Transporteur-3 d'acides aminés excitateurs/métabolisme , Hémodynamique/effets des médicaments et des substances chimiques , Mâle , Mitochondries du myocarde/effets des médicaments et des substances chimiques , Mitochondries du myocarde/métabolisme , Infarctus du myocarde/étiologie , Infarctus du myocarde/génétique , Infarctus du myocarde/métabolisme , Infarctus du myocarde/anatomopathologie , Infarctus du myocarde/physiopathologie , Lésion de reperfusion myocardique/étiologie , Lésion de reperfusion myocardique/génétique , Lésion de reperfusion myocardique/métabolisme , Lésion de reperfusion myocardique/anatomopathologie , Lésion de reperfusion myocardique/physiopathologie , Myocarde/métabolisme , Myocarde/anatomopathologie , Perfusion , Réaction de polymérisation en chaîne , ARN messager/métabolisme , Rats , Rats de lignée WKY , Rat Zucker , Sarcolemme/effets des médicaments et des substances chimiques , Sarcolemme/métabolisme , Facteurs temps , Fonction ventriculaire gauche/effets des médicaments et des substances chimiquesRÉSUMÉ
OBJECTIVE: It is well known that chronic heart failure (CHF) is associated with insulin resistance and cachexia, but little is known about the underlying substrate metabolism. The present study was undertaken to identify disturbances of basal glucose, lipid and protein metabolism. DESIGN: We studied eight nondiabetic patients with CHF (ejection fraction 30 +/- 4%) and eight healthy controls. Protein metabolism (whole body and regional muscle fluxes) and total glucose turnover were isotopically assayed. Substrate oxidation were obtained by indirect calorimetry. The metabolic response to exercise was studied by bicycle ergometry exercise. RESULTS: Our data confirm that CHF patients have a decreased lean body mass. CHF patients are characterised by (i) decreased glucose oxidation [glucose oxidation (mg kg(-1) min(-1)): 1.25 +/- 0.09 (patients) vs. 1.55 +/- 0.09 (controls), P < 0.01] and muscle glucose uptake [a - v diff(glucose) (micromol L(-1)): -10 +/- 25 (patients) vs. 70 +/- 22 (controls), P < 0.01], (ii) elevated levels of free fatty acids (FFA) [FFA (mmol L(-1)): 0.72 +/- 0.05 (patients) vs. 0.48 +/- 0.03 (controls), P < 0.01] and 3-hydroxybutyrate and signs of elevated fat oxidation and muscle fat utilization [a - v diff(FFA) (mmol L(-1)): 0.12 +/- 0.02 (patients) vs. 0.05 +/- 0.01 (controls), P < 0.05] and (iii) elevated protein turnover and protein breakdown [phenylalanine flux (micromol kg(-1) h(-1)): 36.4 +/- 1.5 (patients) vs. 29.6 +/- 1.3 (controls), P < 0.01]. Patients had high circulating levels of noradrenaline, glucagon, and adiponectin, and low levels of ghrelin. We failed to observe any differences in metabolic responses between controls and patients during short-term exercise. CONCLUSIONS: In the basal fasting state patients with CHF are characterized by several metabolic abnormalities which may contribute to CHF pathophysiology and may provide a basis for targeted intervention.
Sujet(s)
Défaillance cardiaque/métabolisme , Hormones/sang , Muscles/métabolisme , Protéines/métabolisme , Sujet âgé , Acides aminés/sang , Glycémie/métabolisme , Indice de masse corporelle , Calorimétrie indirecte , Exercice physique , Épreuve d'effort/méthodes , Acide gras libre/sang , Avant-bras/vascularisation , Défaillance cardiaque/sang , Défaillance cardiaque/physiopathologie , Humains , Métabolisme lipidique , Mâle , Adulte d'âge moyen , Oxydoréduction , Débit sanguin régionalRÉSUMÉ
Pharmacological and technological advances in surgical and interventional coronary treatment modalities have shown reduced cardiovascular mortality in non-diabetic patients, but diabetic patients have not gained the same benefit of invasive treatment as non-diabetics. Although early studies suggest a poorer outcome after angioplasty than after coronary by-pass grafting (CABG) in diabetic patients, more recent studies including improved pharmacological therapy and stent implantation seem to justify increased use of revascularization by percutaneous coronary intervention (PCI) in diabetics with stable and unstable coronary syndromes as the relative benefit in long-term survival, non-fatal myocardial infarction and cerebrovascular accidents is similar. However, diabetic patients are still subject to higher morbidity and mortality after revascularization with CABG and PCI. This is related to increased co-morbidity, metabolic dysregulation, difficulties in obtaining complete revascularization, and more frequent appearance of new lesions as well as restenosis and hemostatic abnormalities. Drug-eluting stents appear to reduce the risk of restenosis, and aggressive antithrombotics also tend to improve the outcome. Unsolved problems are the significance of incomplete revascularization and whether a PCI strategy is associated with a procedure induced progression of the native diabetic vascular disease in treated or untreated vessels. Trials addressing adjunctive treatment and long-term clinical outcome specifically in diabetic patients should clarify these questions.