Death in ventricular fibrillation induced by isoproterenol in DOCA-salt pretreated rats preceded by changes in myocardial electrolytes

Hypokalemia promotes late phase 3 early afterdepolarization and recurrent ventricular fibrillation during isoproterenol infusion in Langendorff perfused rabbit ventricles

BACKGROUND

Hypokalemia and sympathetic activation are commonly associated with electrical storm (ES) in normal and diseased hearts. The mechanisms remain unclear.

OBJECTIVE

The purpose of this study was to test the hypothesis that late phase 3 early afterdepolarization (EAD) induced by IKATP activation underlies the mechanisms of ES during isoproterenol infusion and hypokalemia.

METHODS

Intracellular calcium (Cai) and membrane voltage were optically mapped in 32 Langendorff-perfused normal rabbit hearts.

RESULTS

Repeated episodes of electrically induced ventricular fibrillation (VF) at baseline did not result in spontaneous VF (SVF). During isoproterenol infusion, SVF occurred in 1 of 15 hearts (7%) studied in normal extracellular potassium ([K(+)]o, 4.5 mmol/L), 3 of 8 hearts (38%) in 2.0 mmol/L [K(+)]o, 9 of 10 hearts (90%) in 1.5 mmol/L [K(+)]o, and 7 of 7 hearts (100%) in 1.0 mmol/L [K(+)]o (P <.001). Optical mapping showed that isoproterenol and hypokalemia enhanced Cai transient duration (CaiTD) and heterogeneously shortened action potential duration (APD) after defibrillation, leading to late phase 3 EAD and SVF. IKATP blocker (glibenclamide, 5 μmol/L) reversed the post-defibrillation APD shortening and suppressed recurrent SVF in all hearts studied despite no evidence of ischemia. Nifedipine reliably prevented recurrent VF when given before, but not after, the development of VF. IKr blocker (E-4031) and small-conductance calcium-activated potassium channel blocker (apamin) failed to prevent recurrent SVF.

CONCLUSION

Beta-adrenergic stimulation and concomitant hypokalemia could cause nonischemic activation of IKATP, heterogeneous APD shortening, and prolongation of CaiTD to provoke late phase 3 EAD, triggered activity, and recurrent SVF. IKATP inhibition may be useful in managing ES during resistant hypokalemia.

Effects of aldosterone blockade on left ventricular function and clinical status during acute myocardial infarction

OBJECTIVE

Heart failure is frequently a serious complication of acute myocardial infarction (AMI). ACE inhibitors, Angiotensin II receptor blockers, beta-blockers and aldosterone receptor blockers have been shown to improve outcomes in this setting. This study aimed to determine the effect of spironolactone on the frequency of clinical heart failure, mortality, rehospitalization and left ventricular functions determined by echocardiography.

MATERIAL AND METHODS

A total of 82 patients with STEMI hospitalized within 6-12 h of debut of symptoms were included in the study. The patients were randomly assigned into spironolactone (group A) or placebo (group B) groups after informed consent had been obtained.

RESULTS

All patients were followed for 6 months. There were no statistically significant differences between the two groups when demographic criteria were compared. The incidence of post-MI angina pectoris, rhythm and conduction disturbance during hospitalization was significantly higher in Group B than in Group A. Although not statistically significant, the incidence of clinical heart failure was slightly lower in Group A than in Group B (5% versus 11%). Left ventricular end-diastolic volumes were slightly lower in Group A than in Group B, although statistically this was not significant.

CONCLUSIONS

In concordance with these findings, the ejection fraction was slightly higher in Group A than in Group B, although this was not statistically significant (47% versus 44%). This trend continued during a 6-month follow-up after randomization. Our findings suggest that early administration of aldosterone blockers provides additional benefits after AMI, reducing the incidence of post-MI angina pectoris and rhythm and conduction disturbances.

Aldosterone and aldosterone antagonism in cardiovascular disease: focus on eplerenone (Inspra)

Aldosterone has long been known to mediate water and electrolyte balance by acting on mineralocorticoid receptors in the kidneys. However, recent studies have demonstrated the presence of these receptors in nonclassical locations, including the brain, blood vessels, and the heart. This finding suggests that aldosterone may play a larger role than once appreciated in normal physiologic function and cardiovascular disease. Some of the adverse cardiovascular effects that have been described include cardiac and vascular fibrosis, left ventricular hypertrophy, congestive heart failure, hypertension, endothelial dysfunction, reduced fibrinolysis, and cardiac arrhythmias. In light of these findings, aldosterone receptor blockers have become increasingly more important. This is especially true considering the fact that traditional therapies, such as angiotensin-converting enzyme inhibitors and angiotensin II-receptor blockers, may not be effective in maintaining long-term suppression of aldosterone. Therefore, a great deal of focus has been placed on spironolactone, which has proven to be an effective, albeit nonselective, aldosterone receptor blocker. The Randomized Aldactone Evaluation Study has shown that spironolactone results in a 30% reduction in mortality among patients with severe congestive heart failure. Other studies have shown spironolactone to lower high blood pressure, improve endothelial dysfunction, reduce left ventricular hypertrophy, and lower the incidence of fatal arrhythmias. However, spironolactone, because of its interaction with other steroid receptors, is not without its limitations, which include gynecomastia, breast tenderness, menstrual irregularities, and impotence. As a result, eplerenone (INSPRA), a selective aldosterone blocker, is currently being investigated for its efficacy and side-effect profile compared with spironolactone. Eplerenone has already been approved for the treatment of systemic hypertension, and several clinical trials are currently underway to identify other therapeutic uses for this agent in cardiovascular disease management.

Aldosterone as a mediator in cardiovascular injury

The renin-angiotensin-aldosterone system plays a central role in the development of hypertension and the progression of end-organ damage. Although angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists can initially suppress plasma aldosterone, it is now well established that aldosterone escape may occur, whereby aldosterone levels return to or exceed baseline levels. The classic effects of aldosterone relate mainly to its action on epithelial cells to regulate water and electrolyte balance. However, blood pressure reduction or fluid loss could not account for the results of the Randomized Aldactone Evaluation Study, which showed that a low dose of spironolactone in addition to conventional therapy could decrease the overall risk of mortality by 30% among patients with severe congestive heart failure. The action of aldosterone at nonepithelial sites in the brain, heart, and vasculature is consistent with the presence of mineralocorticoid receptors in these tissues. Aldosterone has a number of deleterious effects on the cardiovascular system, including myocardial necrosis and fibrosis, vascular stiffening and injury, reduced fibrinolysis, endothelial dysfunction, catecholamine release, and production of cardiac arrhythmias. Several studies have now shown vascular and target-organ protective effects of aldosterone receptor antagonism in the absence of significant blood pressure lowering, consistent with a major role for endogenous mineralocorticoids as mediators of cardiovascular injury. The advent of selective aldosterone receptor antagonists such as eplerenone should prove of great therapeutic value in the prevention of cardiovascular disease and associated end-organ damage.

Effects of ethinyl estradiol on isoproterenol-induced death in ventricular fibrillation in DOCA-salt pretreated male and female rats

To assess the effects of ethinyl estradiol on the incidence of death in ventricular fibrillation induced by isoproterenol in DOCA-salt pretreated rats we implanted male and female rats simultaneously with a 20 mg DOCA pellet and pellets containing either ethinyl estradiol or vehicle (wax). Rats drank saline after implantation. After 6 days rats were challenged with a single, sc dose of 150 micrograms of isoproterenol. The average daily dose of estradiol per rat was estimated on the basis of the quantity of pellet lost during 6 days. In male rats the average daily dose of 61.2 +/- 20.2 micrograms/rat of ethinyl estradiol decreased the incidence of mortality by 80%, from 73.3% (11/15) in vehicle treated to 13.3% (2/15) in estradiol treated rats. Death occurred within 19.2 +/- 8.0 minutes from the injection of isoproterenol and was due to ventricular fibrillation. Serum levels of magnesium and potassium were comparable in the two groups both before and after isoproterenol. Isoproterenol induced death in 9 of 11 DOCA-salt pretreated, ovariectomized rats within 22.3 +/- 9.8 minutes. Only 3 of 11 DOCA-salt ovariectomized rats receiving the average daily dose of 28.4 +/- 12.1 micrograms/rat of ethinyl estradiol died. None of 10 ovariectomized untreated rats died from isoproterenol challenge. Serum levels of magnesium and potassium were comparable in the estradiol and vehicle treated groups. The average daily dose of 2.8 +/- 0.42 micrograms/rat of ethinyl estradiol elicited uterine growth but did not influence the incidence of mortality, since 9 out of 16 and 10 out of 16 rats died following isoproterenol in vehicle and estradiol treated DOCA-salt ovariectomized rats. We conclude that only pharmacological doses of estradiol exert protective effects against DOCA-salt induced myocardial sensitization to isoproterenol and that this protection is not associated with relevant changes in serum potassium or magnesium.

Left ventricular structure and performance in middle-aged rats with deoxycorticosterone acetate-salt hypertension

We designed this study to establish the structural and functional characteristics of the hypertrophied left ventricle of middle-aged rats during mineralocorticoid-salt hypertension. Treatment was initiated at 12 months of age, and the rats were studied at either 13 or 15 months of age (after 1 or 3 months of treatment). All rats were unilaterally nephrectomized. One group received deoxycorticosterone acetate (DOCA) injections (30 mg/kg s.c.) biweekly and 1% NaCl drinking water (DOCA salt), and the other group was injected with the vehicle (sesame seed oil) and given tap water to drink (sham). During the first 4 weeks of DOCA-salt treatment, arterial pressure reached its peak and left ventricular enlargement was mainly due to increases of 47% in cardiocyte cross-sectional area in the middle layer of the left ventricular wall. The last 2 months were characterized by an accelerated endomyocardial growth. Because absolute left ventricular mass did not increase during the last 2 months of treatment, we conclude that cellular hypertrophy was accompanied by a focal loss of cardiocytes. Myocardial hydroxyproline concentration was initially elevated by 37% but normalized by the third month of treatment. Intracellularly, myofibril volume percent was not changed, but mitochondria volume percent declined (13% in the midmyocardium and 15% in the endomyocardium) and sarcoplasmic volume density increased by 25% and 39%, respectively, in these regions. Left ventricular hypertrophy was associated with enhanced peak cardiac and stroke indexes, measured during increased preload, after both 1 and 3 months of DOCA-salt treatment. Acceleration of flow, however, was depressed in the rats with left ventricular hypertrophy.(ABSTRACT TRUNCATED AT 250 WORDS)