Ischaemia

PI (adenosine) receptors were explored as therapeutic targets before P2 receptors. Adenosine was identified early and is in current use to treat supraventricular tachycardia. A2a receptor antagonists are being investigated for the treatment of Parkinson s disease and patents have been lodged for the application of PI receptor subtype agonists and antagonists for myocardial ischaemia and reperfusion injury, cerebral ischaemia, stroke, intermittent claudication and renal insufficiency. 

These detailed cell models can be used to study the development in time of processes like myocardial ischaemia (a reduction in coronary blood flow that causes under-supply of oxygen to the cardiac muscle), or effects of genetic mutations on cellular electrophysiology. They allow to predict the outcome of changes in the cell s environment, and may even be used to assess drug actions. 

While the ECG is an invaluable tool for the observation of heart rate and rhythm, as well as for the diagnosis of conduction abnormalities, ischaemia, and infarcts, its detailed interpretation is not without pitfalls. One reason for this is that different changes in cardiac cellular behaviour may give rise to very similar effects on the ECG. This makes it difficult to draw conclusions from a patient s ECG to the underlying (sub-)cellular mechanisms. This issue is usually referred to as the inverse problem. ... 

Rossi DJ, Oshima T, AttweU D (2000) Glutamate release in severe brain ischaemia is mainly by reversed uptake. Nature 403 316-321... 

Dextran 40 40000 10% w/v in 5% w/v glucose injection or 0.9% w/v sodium chloride injection Autoclave IV infusion improves blood flow and tissue function in burns and conditions associated with local ischaemia... 

Ma J, Endres M, Moskowitz MA. Synergistic effects of caspase inhibitors and mk-801 in brain injury after transient focal cerebral ischaemia in mice. Br J Pharmacol 1998 124 756-762. 

Ma J, Qiu J, Hirt L, Dalkara T, Moskowitz MA. Synergistic protective effect of caspase inhibitors and bfgf against brain injury induced by transient focal ischaemia. Br J Pharmacol 2001 133 345-350. 

The European/Australian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT) confirmed the finding of ESPS 2, showing that the combination of aspirin and dipyridamole is more effective than aspirin alone in the prevention of new vascular events in patients with nondisabling cerebral ischaemia of presumed arterial origin. Adding the ESPRIT data to the meta-analysis of previous trials resulted in an overall risk ratio for the composite of vascular death, stroke, or MI of 0.82 (95% Cl 0.74-0.91). 

ESPRIT Study Group, Halkes PH, van Gijn J, Kappelle LJ, Koudstaal PJ, Algra A. Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT) randomised controlled trial. Lancet 2006 367(9523) 1665-1673. 

Several other conditions can provoke this reverse pump type of release. One is when the transmembrane ionic gradient is reversed. Experimentally this is achieved by reducing extracellular Na+. Because the neuronal uptake of monoamines from the synapse by the transporter requires co-transport of Na+ and Cl , reversing the ionic gradient (so that the Na+ concentration is lower outside, than inside, the terminals) will drive the transporter in the wrong direction. Such carrier-mediated release could explain the massive Ca +-independent release of noradrenaline during ischaemia which increases intracellular Na+ concentration and reduces intracellular K+. 

The proposal that NO or its reactant products mediate toxicity in the brain remains controversial in part because of the use of non-selective agents such as those listed above that block NO formation in neuronal, glial, and vascular compartments. Nevertheless, a major area of research has been into the potential role of NO in neuronal excitotoxicity. Functional deficits following cerebral ischaemia are consistently reduced by blockers of NOS and in mutant mice deficient in NOS activity, infarct volumes were significantly smaller one to three days after cerebral artery occlusion, and the neurological deficits were less than those in normal mice. Changes in blood flow or vascular anatomy did not account for these differences. By contrast, infarct size in the mutant became larger... 

Although there is no evidence that the neuronal degeneration of AzD results, as in cardiovascular ischaemia, from the excitotoxicity of increased intracellular Ca +, some calcium channel blockers have been tried in AzD. They have had little effect but surprisingly a pyrrolidone derivative nefiracetam, which opens L-type voltage-sensitive calcium channels (VSCCs) reduces both scopolamine- and )S-amyloid-induced impairments of learning and memory in rats (Yamada et al. 1999). This effect can be overcome by VSCC antagonists, but nefiracetam has not been tried in humans. 

Hydrogen ions accumulate in tissue damaged by inflammation and ischaemia and so pH is lowered. These protons may activate nociceptors directly via their own family of ion channels as well as sensitising them to mechanical stimulation. Acid-sensing ion channels (ASICS) are a family of sodium channels that are activated by protons — of special interest is one type found only in small dorsal root ganglion neurons that possibly are responsible for activation of nociceptors. Although the transduction of mechanical stimuli is poorly understood, ASICs are closely related to channels that respond to stretch. 

Oxidant Stress and the Heart Modulation of Ion Transport Mechanisms During Ischaemia and... 

Figure 4.3 Effect of a variety of anti-free-radical interventions on reperfuslon-induced ventricular fibrillation In the Isolated perfused rat heart. Regional Ischaemia was induced by occluding a snare around the left anterior descending coronary artery and, after 10 min, hearts were reperfused by releasing the snare. Superoxide dismutase (SOD) (1 x 10° U/l), catalase (CAT) (1 X 10 U/l), mannitol (Mann) (50 mM), l-methlonlne (Methlon) (10 mM), glutathione (Glutath) (10 iiM) or desferrioxamlne (Deafer) (150 iim) were included throughout the experimental time course (n = 15/group). Redrawn with permission from Bernier et af. (1986).

Figure 4.4 Effect of a free-radical scavenger M-(2-mercaptoproplonyl)-glycine (MPG) on the recovery of contractile function following 15 min of regional ischaemia in the dog heart, (a) MPG infused 1 min before reperfusion, (b) MPG infused 1 min after reperfusion. Contractile function was assessed as changes in ventricular wall thickening measured using an ultrasonic pulsed-Doppler epicardial probe. Note The free radical scavenger MPG can reduce myocardial stunning only when present during the first minute of reperfusion. Redrawn with permission from Bolli et af. (1989).

During ischaemia, the activity of cellular antioxidant systems may be reduced (Ferrari et al. 1985 GaUnanes etal. 1992). In addition, a number of cellular pathways that produce free radicals are primed during ischaemia such as the xanthine/xanthine oxidase system (McCord, 1987), catecholamine auto-oxidation (Jackson et al., 1986) and the arachadonic acid pathway (Halliwell and Gutteridge, 1989). Thus, during early reperfusion there is a burst of free radical production (see Fig. 4.1) that may overwhelm the antioxidant systems of the cells. 

A sustained inhibition of the Na/K pump following a period of oxidant stress would be expected to raise intracellular sodium and favour calcium influx via the Na/Ca exchanger. Ischaemia and reperflision-induced oxidant stress, therefore, may result in a loss of Na/K pump activity, an eflFect that may involve free-radical-mediated changes in cellular thiol status. 

Table 4.1 Effect of selected thiols, disulphides, amino acids and antioxidants on the time to the onset and the time to reach maximal ischaemic contracture in isolated perfused rat hearts. Hearts were perfused for a control period of 10 min at the end of which global low-flow (10% of control) ischaemia was initiated. The interventions described above were included in the perfusion fluid 5 min prior to the onset and throughout the ischaemic period. The data are shown as means standard errors of the means (n = 6)...

Figure 4.8 Reduction of Na/K ATPase activity in isoiated guinea-pig hearts subjected to ischaemia/reperfusion and its prevention by various agents control non-ischaemic hearts (Nl) guinea-pig hearts subjected to global ischaemia for 2 h and subsequently reperfused for 1 h (IR). In other preparations, superoxide dismutase (SOD) 100 U/ml, catalase (CAT) 150 U/ml, dimethylsulphoxide (DMS) 50 mu, histidine (HIS) 10 mu, vitamin E (TOC)...

Na/K ATPase has been investigated recently. These studies were undertaken to investigate the direct modulatory effects of glutathione on Na/K ATPase activity in the absence of other factors present during ischaemia and reperfusion. 

Although it is widely accepted that ischaemia/ reperfusion-induced oxidant stress is associated with a reduction of Na/K ATPase activity, it is difficult to determine which features of this process are responsible for this effect. A classical approach to this type of problem has been to determine the effect of the application of selected metabolites or agents on the activity of the enzyme of interest, an approach that has been exploited for the sarcolemmal Na/K ATPase and glutathione (Haddock et al., 1990). The application of GSH (O.l-l.OmM) induces a concentration-dependent increase in the activity of a bovine isolated ventricular Na/K ATPase preparation (determined by the ouabain-sensitive hydrolysis of ATP to release inorganic phosphate). In the presence of 1 mM GSH there was a 38% stimulation of activity compared to untreated control... 

Ferrari, R., Ceconi, C., Curello, S., Guamieri, C., Caldarera, C., Albertini, A. and Visioli, O. (1985). Oxygen-mediated myocardial damage during ischaemia and reperfusion role of the cellular defences against oxygen toxicity. J. Mol. Cell. Cardiol. 17, 937-945. 

Ferrari, R, Caigoni, A., Curello, S., Boffa, G.M. and Ceconi, C. (1989). Effects of iloprost (ZK 36374) on glutathione status during ischaemia and reperfusion of isolated rabbit hearts. Br. J. Pharmacol. 98, 678-684. 

Furakawa, T., Kimura, S., Furukawa, N., Bassett, A.L. and Myerburg, R.J. (1991). Role of ATP-regulated potassium channels in differential responses of endocardial and epicardial cells to ischaemia. Circ. Res. 68 1693-1702. 

Parratt, J.R. and Wainwright, C.L. (1987). Failure of allopurinol and a spin trapping agent N- -butyl-alpha-phenyl nitrone to modify significantly ischaemia and tepcrfiision-induced arrhythmias. Br. J. Pharmacol. 91, 49-59. 

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