Shen-Fu Injection Attenuates Postresuscitation Myocardial Dysfunction in a Porcine Model of Cardiac Arrest

Shen-fu Injection Modulates HIF- 1α/BNIP3-Mediated Mitophagy to Alleviate Myocardial Ischemia-Reperfusion Injury

Coronary reperfusion therapy is the most common surgical treatment for myocardial infarction, but it can further induce myocardial ischemia-reperfusion injury (MIRI). Therefore, MIRI following coronary intervention is a challenging clinical issue. This study aims to investigate the involvement of HIF- 1α/BNIP3-mediated mitophagy in the protective effects of Shen-fu Injection (SFI) on MIRI in rats. Key targets and signaling pathways of myocardial MIRI were analyzed using high-throughput transcriptome data from the GSE240842 dataset in the GEO database.To establish the MIRI rat model, the left anterior descending coronary artery was ligated for 30 min, followed by reperfusion for 120 min. Hypoxia/reoxygenation (H/R) in neonatal rat primary cardiomyocytes was induced by oxygen-glucose deprivation for 4 h, followed by reoxygenation for 2 h. Two hours after reperfusion, assessments included myocardial infarction area, CK-MB, CTnI, HE staining, TUNEL, mitochondrial ultrastructure and autophagosomes, HIF- 1α, BNIP3, LC3B-II, LC3B-I protein expression, immunofluorescence, and qRT-PCR. Cardiac function was also evaluated using M-mode ultrasound 2 h after reperfusion. In cardiomyocytes, CCK- 8, EdU cell proliferation levels, scratch assay, mitochondrial membrane potential, ROS levels, cardiomyocyte apoptosis, protein expression levels, and immunofluorescence were assessed 2 h after reoxygenation. Our results indicate that HIF- 1α and BNIP3 are key targets in MIRI. SFI upregulates HIF- 1α expression, promoting moderate mitophagy. This process clears excessively damaged mitochondria, reduces cardiomyocyte apoptosis, and decreases myocardial injury. Additionally, SFI reduces autophagosome accumulation, lowers ROS production, and stabilizes membrane potential. Consequently, the area of myocardial infarction is reduced, and cardiac function is improved. SFI activates the HIF- 1α/BNIP3 pathway to mediate moderate mitophagy, effectively reducing cardiomyocyte apoptosis and alleviating myocardial ischemia-reperfusion injury, thereby protecting cardiomyocytes.

Efficacy and safety of Shenfu injection on bradyarrhythmia: A systematic review and meta-analysis

BACKGROUND

Bradyarrhythmia is a form of arrhythmia commonly seen in clinical settings. This study aims to investigate the efficacy and safety of the Shenfu injection (SFI) in the treatment of bradyarrhythmia.

METHODS

A comprehensive search was conducted in seven databases for randomized controlled trials (RCTs) related to SFI and the treatment of bradyarrhythmia. Primary outcome in this meta-analysis included the overall response rate in clinical symptom improvement. The risk of bias was evaluated utilizing the Cochrane Collaboration's tool.

RESULTS

A total of 28 studies, involving 2143 patients with bradyarrhythmia, were included. The meta-analysis results suggest that SFI treatment is superior to conventional medication alone. Further sensitivity analysis demonstrated that the total response rate in the SFI group was significantly higher than that in the conventional medication group (RR = 1.29; 95% CI: 1.22-1.37; P < .00001). Moreover, the improvement in heart rate in the SFI group was significantly better than that in the conventional medication group (MD = 5.17; 95% CI: 3.77-6.58; P < .00001). In terms of safety, the incidence of adverse events was lower in the SFI treatment group (5.25%, 19/362) compared to the conventional medication alone group (34.04%, 113/332) (RR = 0.20; 95% CI: 0.08-0.51; P < .001).

CONCLUSION

SFI demonstrates significant improvement in the overall response rate and safety for patients with bradyarrhythmia compared to conventional basic therapy. However, due to the presence of potential bias in the included studies, well-designed RCT trials are needed to confirm the efficacy and safety of adjuvant SFI therapy for the treatment of bradyarrhythmia.

Traditional Chinese medicine injections with Tonifying Qi, equivalent effect of regulating energy metabolism, for acute myocardial infarction: a systematic review and meta-analysis of randomized clinical trials

Background

Traditional Chinese medicine injections for Tonifying Qi (TCMi-TQs), which exhibits comparable effect of regulating energy metabolism, is commonly used as an adjuvant treatment for acute myocardial infarction (AMI) in China.

Objective

A systematic review and meta-analysis was conducted to contrast the effectiveness and safety of four TCMi-TQs in AMI.

Methods

Eight Databases were thoroughly searched before 31 July 2024, for randomized controlled trials (RCTs) focusing on the application of TCMi-TQs combined with conventional treatments (CT) to treat AMI. The primary outcomes were in-hospital mortality and long-term mortality. Secondary outcomes included malignant arrhythmia, left ventricular ejection fraction (LVEF), and adverse events. Stata17.0 and RevMan 5.4.1 software were employed for meta-analysis. The quality of evidence was evaluated using the GRADE approach.

Results

A total of 113 RCTs involving 10,779 patients were included in the analysis, none of which described in-dependent testing of the purity or potency of the TCMi-TQ product used. 51/113 reported random sequence generation. All RCTs lack adequate description of allocation concealment. 112/113 failed to assess blinding. The meta-analysis results demonstrated that the combined application of TCMi-TQ + CT, compared with CT, significantly reduced in-hospital mortality in AMI patients [RR = 0.58, 95% CI (0.51, 0.67), P < 0.05], decreased the incidence of malignant arrhythmia [RR = 0.51, 95%CI(0.42, 0.63), P < 0.05], increased LVEF [MD = 6.52, 95%CI(5.54, 7.50), P < 0.05], and decreased the incidence of adverse events [RR = 0.70, 95%CI(0.60, 0.81), P < 0.05]. The GRADE evidence quality classification indicated that the evidence for in-hospital mortality, malignant arrhythmia, and adverse events was of moderate quality, while the evidence for LVEF was of low quality.

Conclusion

TCMi-TQ demonstrates additional clinical value in reducing mortality, the risk of malignant arrhythmia, and adverse events in patients with AMI. However, further validation of these findings is warranted through high-quality clinical trials due to methodological weaknesses in randomization, blinding, allocation concealment, and insufficient assessment of the purity/potency of botanical drugs and the quantity of active metabolites.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/view/CRD42024573818, identifier PROSPERO (CRD42024573818).

Cardiac energy metabolic disorder and gut microbiota imbalance: a study on the therapeutic potential of Shenfu Injection in rats with heart failure

Objective

To investigate the relationship between heart failure (HF) and gut microbiota-mediated energy metabolism, and to explore the role of Shenfu Injection in this process.

Materials and methods

In this study, Adriamycin-induced chronic heart failure (CHF) rat model was used and randomly divided into the blank control group (Normal, n = 9), HF control group (Model, n = 12), Shenfu Injection treatment group (SFI, n = 9), and positive drug control group (TMZ, n = 9). The changes in gut microbiota structure were analyzed by 16S rRNA high-throughput sequencing, the content of short-chain fatty acids (SCFAs) was detected by targeted metabolomics technology, and cardiac function and energy metabolism-related indicators were evaluated.

Results

Myocardial energy metabolism in HF rats was disordered, characterized by reduced fatty acid oxidation, enhanced anaerobic glycolysis of glucose, mitochondrial damage, and decreased ATP content; The gut microbiota of HF rats was imbalanced, with a reduction in beneficial bacteria, an increase in conditional pathogenic bacteria, and impaired intestinal barrier function; Both Shenfu Injection and trimetazidine improved myocardial energy metabolism and cardiac function, but Shenfu Injection was more significant in regulating gut microbiota and improving intestinal health; The production of SCFAs from the gut microbiota of HF rats increased, which may be closely related to myocardial energy metabolism; SCFAs-producing bacteria Akkermansia and Blautia played a key role in the development of HF, and their abundance was positively correlated with SCFAs content.

Conclusion

Shenfu Injection in treating HF may improve myocardial energy metabolism and intestinal health by regulating gut microbiota, especially the abundance of SCFAs-producing bacteria Akkermansia and Blautia, thereby exerting therapeutic effects. This provides theoretical support for treatment strategies based on gut microbiota.

Effectiveness and safety of Shenfu injection in septic patients with hypoperfusion: A multi-center, open-label, randomized, controlled trial

Background

To evaluate the effectiveness and safety of the Shenfu injection (SFI) combined with standard bundle treatment in septic patients with hypoperfusion.

Method

This study was a multi-center, randomized, open-label, controlled trial conducted in four teaching hospitals in China. The septic patients with hypoperfusion and traditional Chinese medicine (TCM) syndrome with Yang-Qi deficiency were enrolled from January 2019, through September 2020. Eligible patients were randomly allocated in a 1:1 ratio to either receive 60 mL of SFI infusion per day plus standard treatment (SFI group) or standard bundle treatment alone (control group). The primary outcome was 28-day all-cause mortality. Secondary outcomes were 90-day all-cause mortality time to weaning from mechanical ventilation, time to weaning from vasopressors, time to discharge from the ICU and hospital, and laboratory results after randomization.

Results

A total of 188 patients completed the trail. This study revealed that the results of the SFI group and the control groups were not statistically significant in 28-day all-cause mortality (10.6% vs. 20.2%, respectively; P=0.106). The infusion of SFI was associated with a significant reduction in the duration of vasopressor use (median=4.0 days, interquartile range [IQR]: 2.0 days-6.0 days vs. median=5.0 days, IQR: 3.0 days-8.0 days, respectively; P=0.043). Patients in the SFI group had statistically greater reductions in plasma lactate levels compared with those in the control group at the first 12 h (median=1.1 mmol/L, IQR: 0.3-2.0 mmol/L vs. median=0.0 mmol/L, IQR: -0.2 to 0.8 mmol/L, respectively; P <0.001) and 24 h (median=1.4 mmol/L, IQR: 0.3-2.2 mmol/L vs. median=0.4 mmol/L, IQR: -0.4 to 1.6 mmol/L, respectively; P=0.001).

Conclusion

SFI plus standard therapy did not significantly decrease 28-day all-cause mortality for septic patients with hypoperfusion and TCM syndrome with Yang-Qi deficiency.Trial registration Chinese Clinical Trial Registry Identifier: ChiCTR1800020435.

Shenfu injection: a review of pharmacological effects on cardiovascular diseases

Shenfu injection (SFI), composed of ginseng and aconite, is a Chinese patent developed from the classic traditional prescription Shenfu Decoction created more than 700 years ago. SFI has been widely used in China for over 30 years for treating cardiovascular diseases. The main components in it include ginsenosides and aconitum alkaloids. In recent years, the role of SFI in the treatment of cardiovascular diseases has attracted much attention. The pharmacological effects and therapeutic applications of SFI in cardiovascular diseases are summarized here, highlighting pharmacological features and potential mechanisms developments, confirming that SFI can play a role in multiple ways and is a promising drug for treating cardiovascular diseases.

Effects of combination therapy with Shenfu Injection in critically ill patients with septic shock receiving mechanical ventilation: A multicentric, real-world study

Background: Septic shock has increasingly become a cause of death threatening human survival. Shenfu Injection (SFI), a patented Chinese medicine, has been widely used in the treatment of patients with sepsis and cardiovascular diseases domestically. We sought to examine whether combination therapy with SFI can improve clinical outcomes in critically ill patients undergoing mechanical ventilation (MV). Methods: This real-world, multicenter retrospective trial enrolled consecutive adult patients with sepsis requiring MV from four medical/surgical intensive care units (ICUs) in China between August 2016 and September 2021. Patients were identified from the medical information department database of each center and assigned to either of two groups (SFI or control) on the basis of the initial treatment received. The primary outcome was 28-day all-cause mortality, and the durations of vasopressor therapy and MV, the ICU length of stay, and costs were assessed as secondary outcomes. Subsequently, we performed a meta-analysis of randomized controlled trials (RCTs) on SFI published before July 2021 to verify our conclusions. Results: 2311 mechanically ventilated patients with septic shock (1128 patients in the SFI group and 1183 in the control group) were analyzed. The survival probability during the first 28 days after admission in the SFI group was greater than that in the control group [p < 0.01 by log-rank test; hazard ratio (HR), 0.56; 95% confidence interval (CI), 0.39-0.72]. Patients in the SFI group also experienced a significantly reduced duration of vasopressor therapy [7.28 (95% CI, 6.14-8.42) vs. 12.06 (95% CI, 10.71-13.41) days, p < 0.001], more ventilator-free days [6.49 (95% CI, 5.42-7.55) vs. 10.84 (95% CI, 9.59-12.09) days, p < 0.001], a shorter ICU length of stay [18.48 (95% CI, 17.59-19.38) vs. 23.77 (95% CI, 22.47-25.07) days, p < 0.001], and more time free from organ failure [14.23 (95% CI, 12.94-15.52) vs. 19.07 (95% CI, 16.09-22.05) days, p < 0.001]. No major adverse effects were reported in either group. Conclusion: Among critically ill patients requiring MV, combination therapy with SFI can improve the survival probability without any obvious adverse reactions.

Effect of Shenfu Injection () on Lactate and Lactate Clearance in Patients with Post-cardiac Arrest Syndrome: A Post Hoc Analysis of a Multicenter Randomized Controlled Trial

OBJECTIVE

To assess the effects of Shenfu Injection (, SFI) on blood lactate, and secondarily its effect on the lactate clearance (LC) in patients with post cardiac arrest syndrome (PCAS).

METHODS

The present study is a post hoc study of a randomized, assessor-blinded, controlled trial. Patients experienced in-hospital cardiac arrest between 2012 and 2015 were included in the predefined post hoc analyses. Of 1,022 patients enrolled, a total of 978 patients were allocated to the control group (486 cases) and SFI (492 cases) group, receiving standardized post-resuscitation care bundle (PRCB) treatment or PRCB combined with SFI (100 mL/d), respectively. Patients' serum lactate was measured simultaneously with artery blood gas, lactate clearance (LC) was calculated on days 1, 3, and 7 after admission and compared between groups. Lactate and LC were also compared between the survivors and non-survivors according to the 28-d mortality, as well as the survivors and non-survivors subgroups both in the SFI and control groups.

RESULTS

In both groups, compared with pre-treatment levels, mean arterial pressure (MAP) and PaO₂ were significantly improved on 1, 3, 7 d after treatment (P<0.05), while heart rate (HR) and blood glucose levels were significantly decreased on 1, 3 and 7 d after treatment (P<0.05). compared with control group, SFI treatment improved the values of MAP and PaO₂ (P<0.05), and significantly decreased the levels of HR and the blood glucose level on 3 and 7 d after treatment (P<0.05). Compared with the control group, lactate levels decreased faster in the SFI group versus the control group on 3 and 7 d (P<0.05). From initiation of treatment and the following 3 and 7 d, SFI treatment greatly increased the LC compared with that in the control group (P<0.05). Compared with survivors, non-survivors had higher admission lactate levels (7.3 ±1.1 mmol/L vs. 5.5 ±2.3 mmol/L; P<0.01), higher lactate levels on days 1, 3 and 7 (P<0.05), and LC were decreased significantly on 3 and 7 d after treatment (P<0.05). Similar results were also found both in the SFI and control groups between survivors and non-survivors subgroups.

CONCLUSION

SFI in combination with PRCB treatment is effective at lowering lactate level and resulted in increasing LC in a targeted population of PCAS patients.

Resolvin D1 Improves Post-Resuscitation Cardiac and Cerebral Outcomes in A Porcine Model of Cardiac Arrest

Following global ischemia reperfusion injury triggered by cardiac arrest (CA) and resuscitation, the ensuing cardiac and cerebral damage would result in high mortality and morbidity. Recently, resolvin D1 has been proven to have a protective effect on regional cardiac and cerebral ischemia reperfusion injury. In this study, we investigated the effects of resolvin D1 on cardiac and cerebral outcomes after cardiopulmonary resuscitation (CPR) in a porcine model.Twenty-eight male domestic pigs weighing between 33 and 41 kg were randomly divided into one of the four groups: sham, CPR, low-dose resolvin D1 (LRD), and high-dose resolvin D1 (HRD). Sham animals underwent the surgical preparation only. Other animals were subjected to 8 min of untreated ventricular fibrillation and then 5 min of CPR. At 5 min after resuscitation, resolvin D1 was intravenously administered with the doses of 0.3 and 0.6 μg/kg in the LRD and HRD groups, respectively. The resuscitated animals were monitored for 6 h and observed for an additional 18 h.After resuscitation, myocardial and neurological function were significantly impaired, and their serum levels of injury biomarkers were markedly increased in the CPR, LRD, and HRD groups compared with the sham group. In addition, tissue inflammation and oxidative stress in the heart and brain were observed in the three groups. However, myocardial function was significantly improved and its injury biomarker was significantly decreased starting 3 h after resuscitation in the LRD and HRD groups compared with the CPR group. Similarly, neurological function was significantly better at 24 h post-resuscitation and its injury biomarkers were significantly lower at 6 and 24 h post-resuscitation in the LRD and HRD groups than in the CPR group. In addition, myocardial, cerebral inflammation, and oxidative stress were significantly milder in the two resolvin D1-treated groups. Especially, HRD produced significantly greater post-resuscitation cardiac and cerebral protection compared with the LRD group.In conclusion, resolvin D1 significantly improved post-resuscitation cardiac and cerebral outcomes in a porcine model of CA, in which the protective effects may be in a dose-dependent manner.

Shenfu injection improves cerebral microcirculation and reduces brain injury in a porcine model of hemorrhagic shock

BACKGROUND

Shenfu injection (SFI) is a traditional Chinese herbal medicine which has been clinically used for treatment of septic shock and cardiac shock. The aim of this study was to clarify effects of SFI on cerebral microcirculation and brain injury after hemorrhagic shock (HS).

METHODS

Twenty-one domestic male Beijing Landrace pigs were randomly divided into three groups: SFI group (SFI, n = 8), saline group (SA, n = 8) or sham operation group (SO, n = 5). In the SFI group, animals were induced to HS by rapid bleeding to a mean arterial pressure of 40 mmHg within 10 minutes and maintained at 40±3 mmHg for 60 minutes. Volume resuscitation (shed blood and crystalloid) and SFI were given after 1 hour of HS. In the SA group, animals received the same dose of saline instead of SFI. In the SO group, the same surgical procedure was performed but without inducing HS and volume resuscitation. The cerebral microvascular flow index (MFI), nitric oxide synthase (NOS) expression, aquaporin-4 expression, interleukin-6, tumor necrosis factor-α (TNF-α) and ultrastructural of microvascular endothelia were measured.

RESULTS

Compared with the SA group, SFI significantly improved cerebral MFI after HS. SFI up regulated cerebral endothelial NOS expression, but down regulated interleukin-6, TNF-α, inducible NOS and aquaporin-4 expression compared with the SA group. The cerebral microvascular endothelial injury and interstitial edema in the SFI group were lighter than those in the SA group.

CONCLUSIONS

Combined application of SFI with volume resuscitation after HS can improve cerebral microcirculation and reduce brain injury.

Effects of Shenfu Injection () on Inflammatory Response during Post-Resuscitation Myocardial Dysfunction after Cardiac Arrest in Swine

Objective

To investigate whether Shenfu Injection (SFI, 参附注射液) can alleviate post-resuscitation myocardial dysfunction by inhibiting the inflammatory response.

Methods

After 8 min of ventricular fibrillation and 2 min of basic life support, 24 pigs were randomly divided into 3 groups (n=8), which were given intravenous bolus injections of SFI (1.0 mL/kg), epinephrine (EP, 0.02 mg/kg) and normal saline (SA), respectively. The animals were sacrificed at 24 h after restoration of spontaneous circulation (ROSC), and serum interleuking-6 (IL-6) and tumor necrosis factor-α (TNF-α) levels were measured by enzyme-linked immunosorbent assay (ELISA); expressions of Toll-like receptor 4 (TLR4)/nuclear factor kappa B (NF-κB) mRNAs and proteins were determined by RT-PCR and Western blot, respectively.

Results

Compared with the EP and the SA groups, the ultrastructure of myocardial cells were slightly damaged and the systolic function of the left ventricle was markedly improved in the SFI group at 24 h after ROSC (P<0.05). In addition, compared with the EP and SA groups, the SFI group also showed significantly reduced levels of serum IL-6 and TNF-α, protein and mRNA levels of myocardial NF- κB and TLR4 (P<0.05).

Conclusions

Activation of TLR4/NF-κB signaling pathway may be involved in the pathological mechanisms of post-resuscitation myocardial dysfunction. SFI may block NF-κB-mediated inflammatory response by reducing the activity of NF- κB and the level of TNF-α, thus playing a protective role in post-resuscitation myocardial dysfunction.

Effect of shenfu injection on microcirculation in shock patients: A protocol for systematic review and meta-analysis

BACKGROUND

Shock is a major public health problem worldwide. At present, the morbidity and mortality of shock patients are relatively high. Vasomotor dysfunction is 1 of the key pathological aspects of shock. Shenfu injection has been widely used for the treatment of shock in China. Pharmacological studies have suggested that Shenfu injection can reduce peripheral circulation resistance and improve microcirculation. The purpose of this study is to evaluate the effect and safety of Shenfu injection on the microcirculation of patients with shock.

METHODS

This review summarizes and meta-analyzes randomized controlled trials of Shenfu injection for the treatment of shock.Searched the following electronic databases: PubMed, Cochrane Library, Embase, CNKI, VIP and Wanfang Data. The Cochrane risk assessment tool was used to evaluate the methodological quality of randomized controlled trials. All tests are analyzed according to the standards of the Cochrane Handbook. Review Manager 5.3, R-3.5.1 software and Grading of Recommendations Assessment, Development, and Evaluation pro GDT web solution are used for data synthesis and analysis.

RESULTS

This review focuses on the effects of Shenfu injection on the microcirculation of shock patients (blood lactic acid level, arteriovenous oxygen saturation, arteriovenous carbon dioxide partial pressure difference, sublingual microcirculation), 28-day mortality, 28-day ICU hospitalization and adverse reaction rate.

CONCLUSION

This review provides a clear basis for evaluating the impact of Shenfu injection on the microcirculation of shock patients, as well as the effectiveness and safety of the treatment.

The Effects of Dexmedetomidine Post-Conditioning on Cardiac and Neurological Outcomes After Cardiac Arrest and Resuscitation in Swine

INTRODUCTION

One of the main contents of post-resuscitation care is to alleviate cardiac and neurological damage in cardiac arrest (CA) victims. Recently, dexmedetomidine pre- and post-conditioning have been shown to both effectively protect the heart and brain against regional ischemia reperfusion injury. In this study, we investigated the effects of dexmedetomidine post-conditioning on cardiac and neurological outcomes after CA and resuscitation in swine.

METHODS

A total of 28 male domestic swine were randomized into four groups: sham, cardiopulmonary resuscitation (CPR), low-dose dexmedetomidine post-conditioning (LDP), and high-dose dexmedetomidine post-conditioning (HDP). Sham animals underwent the surgical preparation only. The animal model was established by 8 min of CA and then 5 min of CPR. After the animal was successfully resuscitated, a loading dose of 0.25 μg/kg of dexmedetomidine was intravenously injected followed by continuous infusion of 0.25 μg/kg/h for 6 h in the LDP group, and meanwhile a double dose of dexmedetomidine was similarly administered in the HDP group. The same amount of saline was given in the other two groups. All the resuscitated animals were monitored for 6 h and then returned to their cages for an additional 18 h of observation.

RESULTS

After resuscitation, significantly greater cardiac, neurological dysfunction, and injuries were observed in all animals experiencing CA and resuscitation when compared with the sham group. However, the severity of cardiac and neurological damage was significantly milder in the two dexmedetomidine-treated groups than in the CPR group. Dexmedetomidine post-conditioning also significantly decreased post-resuscitation tissue inflammation, oxidative stress, and cell apoptosis and necroptosis in the heart and brain when compared with the CPR group. In addition, these protective effects produced by dexmedetomidine post-conditioning were significantly greater in the HDP group than in the LDP group.

CONCLUSIONS

Dexmedetomidine post-conditioning dose-dependently improved post-resuscitation cardiac and neurological outcomes through the inhibition of tissue inflammation, oxidative stress, and cell apoptosis and necroptosis.

Adenoviral βARKct Cardiac Gene Transfer Ameliorates Postresuscitation Myocardial Injury in a Porcine Model of Cardiac Arrest

OBJECTIVE

The aim of the study was to determine whether the inhibition of the G-protein-coupled receptor kinase 2 by adenoviral βARKct cardiac gene transfer can ameliorate postresuscitation myocardial injury in pigs with cardiac arrest (CA) and explore the mechanism of myocardial protection.

METHODS

Male landrace domestic pigs were randomized into the sham group (anesthetized and instrumented, but ventricular fibrillation was not induced) (n = 4), control group (ventricular fibrillation 8 min, n = 8), and βARKct group (ventricular fibrillation 8 min, n = 8). Hemodynamic parameters were monitored continuously. Blood samples were collected at baseline, 30 min, 2 h, 4 h, and 6 h after the return of spontaneous circulation (ROSC). Left ventricular ejection fraction was assessed by echocardiography at baseline and 6 h after ROSC. These animals were euthanized, and the cardiac tissue was removed for analysis at 6 h after ROSC.

RESULTS

Compared with those in the sham group, left ventricular +dp/dtmax, -dp/dtmax, cardiac output (CO), and ejection fraction (EF) in the control group and the βARKct group were significantly decreased at 6 h after the restoration of spontaneous circulation. However, the βARKct treatment produced better left ventricular +dp/dtmax, -dp/dtmax, CO, and EF after ROSC. The βARKct treatment also produced lower serum cardiac troponin I, CK-MB, and lactate after ROSC. Furthermore, the adenoviral βARKct gene transfer significantly increased β1 adrenergic receptors, SERCA2a, RyR2 levels, and decreased GRK2 levels compared to control.

CONCLUSIONS

The inhibition of GRK2 by adenoviral βARKct cardiac gene transfer can ameliorate postresuscitation myocardial injury through beneficial effects on restoring the sarcoplasmic reticulum Ca-handling proteins expression and upregulating the β1-adrenergic receptor level after cardiac arrest.

Effect of Shenfu Injection on Porcine Renal Function after Cardiopulmonary Resuscitation

Objective

To comprehensively evaluate the protective effect of Shenfu injection (SFI) on renal ischaemia/reperfusion injury (IRI) after cardiopulmonary resuscitation (CPR) through neutrophil gelatinase-associated lipocalin (NGAL) and to explore effective monitoring of early renal injuries after CPR.

Methods

Thirty healthy minipigs were randomly divided into 3 groups: sham operation (SO) (n = 6), control (n = 12), and SFI (n = 12). The SO group underwent only catheterization, whereas the control and SFI groups were subjected to program-controlled electrical stimulation to establish a cardiac arrest (CA) model due to ventricular fibrillation. After CPR, the return of spontaneous circulation was achieved. Each animal in the SFI group was intravenously injected with SFI after resuscitation. Haemodynamic parameters were monitored at baseline and 2, 6, 12, and 24 hr after CPR. At each time point, venous blood samples were collected for NGAL, creatinine, and ATPase screening.

Results

After CA, the MAP, CPP, and CO of the animals in the control and SFI groups decreased significantly. However, at 6 hr after CPR, the MAP, CPP, and CO of the animals in the SFI group began to recover gradually; the differences between the control and SFI groups were significant (P < 0.005). The renal damage immediately after CPR appeared to be significant in the pathological examinations. However, the degree of renal injury in the SFI group improved significantly, and the apoptosis index was also notably reduced. The blood and urine NGAL levels were clearly elevated after CPR. The greatest increase in NGAL was found in the control group, which was significantly different from that of the SFI group (P < 0.001). SFI can significantly increase the ATPase activity of kidney tissues after CPR and improve abnormal caspase-3 protein expression.

Conclusion

SFI can effectively prevent acute kidney injuries caused by CPR through improving energy metabolism and inhibiting apoptosis.

Shenfu injection prolongs survival and protects the intestinal mucosa in rats with sepsis by modulating immune response

BACKGROUND/AIMS

The aim of present study was to assess the protective effects of Shenfu injection (SI) on the intestinal mucosa and its regulation on the mucosal immune responses in rats with sepsis.

MATERIALS AND METHODS

Sprague-Dawley rats were randomly divided into the sham, model, low-dose SI (LSF), and high-dose SI (HSF) groups. Sham animals underwent laparotomy only, whereas sepsis was modeled by cecal ligation and puncture in the remaining groups. At 2 h post-surgery, the LSF and HSF groups were intraperitoneally administered 5 and 20 mL/kg SI, respectively, whereas other animals with saline. At 12 h and 24 h post-surgery, eight rats per group were sacrificed, and blood and intestinal tissues were collected. The intestinal mucosa was analyzed by hematoxylin and eosin staining. Serum tumor necrosis factor (TNF)-α and interleukin (IL)-6 concentrations, as well as secretory immunoglobulin A (sIgA) content in the intestinal mucosa, were evaluated by enzyme-linked immunosorbent assay. CD3 and γδT lymphocytes were quantified by flow cytometry. Animal survival until 72 h was also recorded.

RESULTS

Intestinal mucosal injury was significantly higher in model animals than in sham animals at postoperative 12 h and 24 h. Serum TNF-α and IL-6 levels were markedly increased, whereas sIgA and CD3 and γδT cell amounts were overtly decreased (p<0.01). The LSF and HSF rats showed lower mortality, intestinal mucosal injury, and serum TNF-α and IL-6 levels (p<0.05), as well as higher sIgA levels and CD3 and γδT cell amounts, than the model group (p<0.01), with a dose-dependent manner.

CONCLUSION

SI dose-dependently prolongs survival and protects the intestinal mucosa in rats with sepsis, possibly through strengthening innate immunity instead of acquired immunity.

Extracorporeal membrane oxygenation mitigates myocardial injury and improves survival in porcine model of ventricular fibrillation cardiac arrest

INTRODUCTION

Despite decades of improved strategy in conventional cardiopulmonary resuscitation (CCPR), survival rates of favorable neurological outcome after cardiac arrest (CA) remains poor. It is indicated that the survival rate of successful resuscitation of extracorporeal membrane oxygenation (ECMO) is superior to that of CCPR. But the effect of ECMO in heart is unclear. We aimed to investigate whether ECMO produces cardiac protection by ameliorating post-ischemia reperfusion myocardial injury and myocardial apoptosis.

METHODS

After undergoing 8-min untreated ventricle fibrillation (VF) and 6-min basic life support, 20 male pigs were ultimately used in this study and randomly divided into two groups: CCPR group (n = 10) and extracorporeal CPR (ECPR) group (n = 10). Hemodynamics and blood samples were obtained at baseline and 1, 2, 4, and 6 h during resuscitation. The successfully resuscitated pigs were sacrificed at 6 h after return of spontaneous circulation (ROSC), and the hearts were removed and analyzed under electron microscopy, and immunohistochemistry, quantitative real-time polymerase chain reaction, and immunofluorescence staining assay were performed to evaluate myocardial injury and myocardial apoptosis.

RESULTS

There were no significant differences at basic hemodynamic status between the two groups. The survival rate of ECPR was significantly higher than CCPR group (10/10 [100%] vs. 4/10 [40%], P = 0.04). Compared to CCPR group, ECPR group exhibited a better outcome in hemodynamic function. Cardiac function was significantly impaired after ROSC in both groups, but left ventricular ejection fraction (LVEF) was significantly elevated in ECPR group than CCPR group. The expression of myocardial injury biomarkers (CK-MB, cTNI, H-FABP), endothelial injury biomarker (sP-selectin), and cardiac function biomarker (BNP) were remarkably increased after ROSC in both groups, but low levels in ECPR group than in CCPR group. Cardiomyocytes injury was attenuated in ECPR group under transmission electron microscopy (TEM). Typical apoptotic nuclei of cardiomyocytes were significantly reduced and oxidative damage were attenuated in ECPR group.

CONCLUSIONS

During prolonged VF-induced CA, ECPR contributes to improving hemodynamics, attenuating myocardial ischemia-reperfusion injury, ameliorating myocardial ultra structure, improving cardiac function, and elevating survival rate by preventing oxidative damage, regulating energy metabolism, inhibiting cardiomyocyte apoptosis.

ECMO attenuates inflammation response and increases ATPase activity in brain of swine model with cardiac arrest compared with CCPR

Extracorporeal membrane oxygenation (ECMO) could increase survival rate and neurological outcomes of cardiac arrest (CA) patients compared with conventional cardiopulmonary resuscitation (CCPR). Currently, the underlying mechanisms how ECMO improves neurological outcomes of CA patients compared with CCPR have not been revealed. A pig model of CA was established by ventricular fibrillation induction and then underwent CCPR or ECMO. Survival and hemodynamics during the 6 h after return of spontaneous circulation (ROSC) were compared. The levels of inflammatory cytokines and Ca²⁺-ATPase and NA⁺-K⁺-ATPase activities were detected. Brain tissues histology and ultra-microstructure in CCPR and ECMO groups were also examined. Results suggested that ECMO significantly improved the survival of pigs compared with CCPR. Heart rate (HR) decreased while cardiac output (CO) increased along with the time after ROSC in both ECMO and CCPR groups. At each time point, HR in ECMO groups was lower than that in CCPR group while CO and mean arterial pressure in ECMO group was higher than CCPR group. In ECMO group, lower levels of IL-1, IL-1β, IL-6, TNFα, and TGFβ, especially IL-1, IL-6, TNFα, and TGFβ, were found compared that in CCPR group while no difference of IL-10 between the two groups was observed. Similar with the results from enzyme-linked immunosorbent assay, decreased expressions of IL-6 and TGFβ were also identified by Western blotting. And Ca²⁺-ATPase and NA⁺-K⁺-ATPase activities were increased by ECMO compared with CCPR. Hematoxylin and eosin staining and ultra-microstructure examination also revealed an improved inflammation situation in ECMO group compared with CCPR group.

Coagulofibrinolytic Changes in Patients with Post-cardiac Arrest Syndrome

Whole-body ischemia and reperfusion due to cardiac arrest and subsequent return of spontaneous circulation constitute post-cardiac arrest syndrome (PCAS), which consists of four syndromes including systemic ischemia/reperfusion responses and post-cardiac arrest brain injury. The major pathophysiologies underlying systemic ischemia/reperfusion responses are systemic inflammatory response syndrome and increased coagulation, leading to disseminated intravascular coagulation (DIC), which clinically manifests as obstruction of microcirculation and multiple organ dysfunction. In particular, thrombotic occlusion in the brain due to DIC, referred to as the "no-reflow phenomenon," may be deeply involved in post-cardiac arrest brain injury, which is the leading cause of mortality in patients with PCAS. Coagulofibrinolytic changes in patients with PCAS are characterized by tissue factor-dependent coagulation, which is accelerated by impaired anticoagulant mechanisms, including antithrombin, protein C, thrombomodulin, and tissue factor pathway inhibitor. Damage-associated molecular patterns (DAMPs) accelerate not only tissue factor-dependent coagulation but also the factor XII- and factor XI-dependent activation of coagulation. Inflammatory cytokines are also involved in these changes via the expression of tissue factor on endothelial cells and monocytes, the inhibition of anticoagulant systems, and the release of neutrophil elastase from neutrophils activated by inflammatory cytokines. Hyperfibrinolysis in the early phase of PCAS is followed by inadequate endogenous fibrinolysis and fibrinolytic shutdown by plasminogen activator inhibitor-1. Moreover, cell-free DNA, which is also a DAMP, plays a pivotal role in the inhibition of fibrinolysis. DIC diagnosis criteria or fibrinolysis markers, including d-dimer and fibrin/fibrinogen degradation products, which are commonly tested in patients and easily accessible, can be used to predict the mortality or neurological outcome of PCAS patients with high accuracy. A number of studies have explored therapy for this unique pathophysiology since the first report on "no-reflow phenomenon" was published roughly 50 years ago. However, the optimum therapeutic strategy focusing on the coagulofibrinolytic changes in cardiac arrest or PCAS patients has not yet been established. The elucidation of more precise pathomechanisms of coagulofibrinolytic changes in PCAS may aid in the development of novel therapeutic targets, leading to an improvement in the outcomes of PCAS patients.

Efficacy and Safety of Combination Therapy of Shenfu Injection and Postresuscitation Bundle in Patients With Return of Spontaneous Circulation After In-Hospital Cardiac Arrest: A Randomized, Assessor-Blinded, Controlled Trial

OBJECTIVES

Postresuscitation care bundle treatment after return of spontaneous circulation in patients experiencing in-hospital cardiac arrest can improve patients' survival and quality of life. The aim of the study was to evaluate the efficacy and safety of combined therapy of Shenfu injection and postresuscitation care bundle in these patients.

DESIGN

Prospective, randomized, controlled clinical study.

SETTING

Fifty hospitals in China.

PATIENTS

Adult patients had experienced in-hospital cardiac arrest between 2012 and 2015.

INTERVENTIONS

Based on the standardized postresuscitation care bundle treatment, patients were randomized to a Shenfu injection group (Shenfu injection + postresuscitation care bundle) or control group (postresuscitation care bundle) for 14 days or until hospital discharge. In the Shenfu injection group, 100 mL Shenfu injection was additionally administered via continuous IV infusion, bid.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was 28-day survival after randomization. The secondary outcomes included 90-day survival as well as the duration of mechanical ventilation and the hospital stay and the total cost of hospitalization. Of 1,022 patients enrolled, a total of 978 patients were allocated to the two groups: the control (n = 486) and Shenfu injection (n = 492) groups. The Shenfu injection group had a significantly greater 28-day survival rate (42.7%) than the control group (30.1%). Also, the Shenfu injection group had a significantly higher survival rate at 90 days (39.6%) than the control group (25.9%). Compared with patients in the control group, patients in the Shenfu injection group had lower risks of 28-day mortality (hazard ratio, 0.61; 95% CI, 0.43-0.89; p = 0.009) and 90-day mortality (hazard ratio, 0.55; 95% CI, 0.38-0.79; p = 0.002). In the Shenfu injection group, the duration of mechanical ventilation (8.6 ± 3.2 vs 12.7 ± 7.9 d; p < 0.001) and the hospital stay (8.7 ± 5.9 vs 13.2 ± 8.1 d; p < 0.001) were significantly less than in the control group. Irreversible brain damage was the main cause of death in both groups. No serious drug-related adverse event was recorded.

CONCLUSIONS

This study demonstrates that Shenfu injection in combination with conventional postresuscitation care bundle treatment is effective at improving clinical outcomes in patients with return of spontaneous circulation after in-hospital cardiac arrest.

Effects of Shenfu Injection () on cerebral metabolism in a porcine model of cardiac arrest

OBJECTIVE

To investigate the effects of Shenfu Injection (, SFI) on cerebral metabolism in a porcine model of cardiac arrest (CA).

METHODS

Thirty Wuzhishan minipigs were randomly assigned to the control group (n=6), epinephrine group (EP group, n=12) and Sfigroup (n=12). After 8 min of untreated ventricular fifibrillation (VF), pigs in the EP group or Sfigroup were administered with either EP (0.02 mg/kg) or Sfi(1.0 mL/kg), respectively. After successful resuscitation, cerebrospinal fluid (CSF) levels of glucose, pyruvate, lactate, glutamate and glycerol were measured at 1, 6, 12 and 24 h after recover from spontaneous circulation (ROSC). In addition, neurologic defificit score (NDS) was calculated at 24 h after ROSC. Surviving pigs were killed at 24 h after ROSC, and the brain tissue was obtained for ultra-microstructure examination.

RESULTS

Compared with the EP group, CSF glucose and pyruvate levels were higher (all P<0.01), and lactate levels were lower in the Sfigroup (P<0.01). Meanwhile, CSF glutamate and glycerol levels in the Sfigroup were lower in comparison to the EP group (all P<0.05). In addition, Sfidecreased NDS at 24 h after ROSC (P<0.01), and alleviated the histopathological damage of the brain.

CONCLUSIONS

Sficould alleviate brain injury after CA, which may be associated with improving cerebral metabolism.

Effect of Shen-Fu Injection Pretreatment to Myocardial Metabolism During Untreated Ventricular Fibrillation in a Porcine Model

Background:

Shen-Fu injection (SFI) can attenuate ischemia-reperfusion injury, protect cardiac function, and improve microcirculation during cardiopulmonary resuscitation. We hypothesized that SFI may also have an influence on myocardial metabolism during ventricular fibrillation (VF). In this study, we used SFI pretreatment prior to VF to discuss the changes of myocardial metabolism and catecholamine (CA) levels during untreated VF, trying to provide new evidence to the protection of SFI to myocardium.

Methods:

Twenty-four pigs were divided into three groups: Saline group (SA group), SFI group, and SHAM operation group (SHAM group). Thirty minutes prior to the induction of VF, the SFI group received 0.24 mg/ml SFI through an intravenous injection; the SA group received an equal amount of sodium chloride solution. The interstitial fluid from the left ventricle (LV) wall was collected through the microdialysis tubes during VF. Adenosine diphosphate (ADP), adenosine triphosphate (ATP), and Na⁺ -K⁺ -ATPase and Ca2⁺ -ATPase enzyme activities were measured after untreated VF. Peak-to-trough VF amplitude and median frequency were analyzed for each of these 5-s intervals.

Results:

The levels of glucose and glutamate were lower after VF in both the SA and SFI groups, compared with baseline, and the levels in the SFI group were higher than those in the SA group. Compared with baseline, the levels of lactate and the lactate/pyruvate ratio increased after VF in both SA and SFI groups, and the levels in the SFI group were lower than those in the SA group. In both the SA and SFI groups, the levels of dopamine, norepinephrine, and epinephrine increased significantly. There were no statistical differences between the two groups. The content of ATP, ADP, and phosphocreatine in the SFI group was higher than those in the SA group. The activity of LV Na⁺ -K⁺ -ATPase was significantly higher in the SFI group than in the SA group. Amplitude mean spectrum area (AMSA) was significantly lower in the SA and SFI groups at 8- and 12-min compared with 4-min. The AMSA in the SFI group was higher than that in the SA group at each time point during untreated VF.

Conclusions:

SFI pretreatment can improve myocardial metabolism and reduce energy exhaustion during VF, and it does not aggravate the excessive secretion of endogenous CAs.

New horizon in the treatment of sepsis: a systematic review of alternative medicine

BackgroundDespite great advancement in treatment of sepsis, mortality of sepsis remains unacceptably high, even with the modern antibiotic and intensive care technologies. Considering the key role of immune dysfunction in sepsis pathophysiology, different treatments were evaluated, but failed to improve survival of patients. Natural remedies have been tested in various studies to overcome sepsis. In this study, we aim to review some of the evidence from clinical, in vitro and in vivo studies about the effect of alternative medicine on sepsis management. MethodsThe following databases were searched up to March 2014: PubMed, Scopus, Web of Science, Ovid and Google Scholar using combination of Mesh term. All in vitro and in vivo studies, also clinical trials, published in English, which evaluated alternative medicine in management of sepsis were included. Results Out of 95 relevant studies, the inclusion criteria were met for 79 cases. Among them, 18 studies were performed on humans. The most herbal medicine, including Xubijing (n=10) and then Rhubarb (n=3). Most of the reviewed botanical medicines modulate the immune system. Reduction of mortality was also reported in studies. ConclusionsModulation of immune system, anti-inflammatory activities and improvement of survival were the action of herbal medicine. A monovalent approach is not enough for treatment of sepsis, we recommend further studies to identify active component of herbal and use them in combination. Also an animal model of sepsis does not exactly mimic human sepsis, so more clinical studies should be performed. With no new drug on the horizon, herbal medicine will be promising for treatment of sepsis.

Pharmacokinetic evaluation of Shenfu Injection in beagle dogs after intravenous drip administration

Shenfu Injection (SFI) is a well-defined Chinese herbal formulation that is obtained from red ginseng and processed aconite root. The main active constituents in SFI are ginsenosides and aconitum alkaloids. In this work, ginsenosides (ginsenoside Rg1, ginsenoside Rb1 and ginsenoside Rc) and aconitum alkaloids (benzoylmesaconine and fuziline) were used as the index components to explore the pharmacokinetic behavior of SFI. A selective and sensitive HPLC–MS/MS method was developed for the quantification of ginsenosides and aconitum alkaloids in dog plasma and was used to characterize the pharmacokinetics of the five index components after intravenous drip of three different dosages of SFI in beagle dogs. The pharmacokinetic properties of the index components were linear over the dose range of 2–8 mL/kg.

Comparison of Shenfu Injection () and epinephrine on catecholamine levels in a porcine model of prolonged cardiac arrest

OBJECTIVE

To compare the effects of Shenfu Injection (SFI) and epinephrine (EPI) on catecholamine levels in a porcine model of prolonged cardiac arrest (CA).

METHODS

After 8 min of untreated ventricular fibrillation, 24 Wuzhishan miniature pigs were randomly assigned to one of the three groups (n=8 per group) and received central venous injection, respectively: SFI group (1 mL/kg), EPI group (20 μg/kg EPI), and normal saline (NS) group. Cardiac output (CO), maximum rate of increase/decrease in left ventricular pressure (±dp/dt), serum levels of EPI, norepinephrine (NE), and dopamine (DA) were determined at baseline and at 0.5, 1, 2, and 4 h after restoration of spontaneous circulation.

RESULTS

The duration of cardiopulmonary resuscitation was shorter in the EPI and SFI groups than in the NS group (P<0.05). The EPI level increased significantly after restoration of spontaneous circulation (ROSC) in all three groups, and was significantly different between the EPI group and the other two groups immediately after ROSC (both P<0.01), but these differences gradually disappeared over time. There were no significant differences in NE or DA levels among the three groups, and there were no correlations between catecholamine levels and CO or dp/dt (P>0.05).

CONCLUSIONS

SFI did not significantly affect endogenous catecholamine levels during cardiopulmonary resuscitation after prolonged ventricular fibrillation. However, SFI improved oxygen metabolism, and produced a better hemodynamic status compared with EPI. SFI might be a potentially vasopressor drug for the treatment of CA.

Effects of Shenfu injection on macrocirculation and microcirculation during cardiopulmonary resuscitation

AIM OF THE STUDY

To examine the effects of Shenfu injection (SFI) on macrocirculation and microcirculation during ventricular fibrillation (VF) and cardiopulmonary resuscitation (CPR).

MATERIALS AND METHODS

Sixteen female Landrace pigs were used in this study. After anesthesia, coronary perfusion pressure (CPP) was measured, and then the abdominal cavity was opened to observe the mesenteric microcirculation with the aid of sidestream dark field imaging. Following the guidelines, we determined microvascular flow index, perfused vessel density and proportion of perfused vessels both for large (diameter>20 μm) and small (diameter<20 μm) microvessels. SFI (1 ml/kg) or saline was given by vein injection at 1h before inducing VF. CPR was initiated after 4 min VF.

RESULTS

The shocks and duration of CPR were less in the SFI group compared with saline group. As the occurrence of VF, the CPP suddenly dropped to near zero, and cannot be measured in the both groups. However, there was greater CPP during CPR and at 1h after return of spontaneous circulation in the SFI group than saline group. Compared with saline, SFI significantly improved the microcirculation parameters of large and small microvessels during VF and CPR.

CONCLUSIONS

SFI can improve the microvascular blood flow and CPP during VF and CPR, and reduce the shocks and duration of CPR.

Effects of Chinese medicine shen-fu injection on the expression of inflammatory cytokines and complements during post-resuscitation immune dysfunction in a porcine model

OBJECTIVE

To investigate the action of Shen-Fu Injection (SFI) in regulating the expression of the serum complements and inflammatory cytokines synthesized and released in response to the stress of global ischemia accompanying cardiac arrest (CA) and resuscitation.

METHODS

Thirty pigs were randomly divided into the sham (n=6) and 3 returns of spontaneous circulation (ROSC) groups (n=24). After 8-min untreated ventricular fibrillation and 2-min basic life support, 24 pigs of the ROSC groups were randomized into three groups (n=8 per group), which received central venous injection of SFI (SFI group), epinephrine (EP group), or saline (SA group). Hemodynamic status and blood samples were obtained at 0, 0.5, 1, 2, 4, 6, 12, and 24 h after ROSC.

RESULTS

Serum concentrations of specific activation markers of the complement system C3, C4 and C5b-9 were increased during cardiopulmonary resuscitation through 24 h after ROSC. There were intense changes of various pro-inflammatory cytokines and anti-inflammatory cytokines as early as 0.5 h after CA. Compared with the EP and SA groups, SFI treatment reduced the proinflammatory cytokines levels of interleukin (IL)-6, IL-8 and tumor necrosis factor α (TNF-α, P<0.05), and increased the anti-inflammatory cytokine levels of IL-4 and IL-10 (P<0.05). Further, SFI treatment decreased the values of C3, C4 and C5b-9 compared with the EP and SA groups.

CONCLUSIONS

SFI, derived from the ancient Chinese medicine, has significant effects in attenuating post-resuscitation immune dysfunction by modulating the expression of complements and cytokines levels. The current study provided an experimental basis for the clinical application of a potential pharmacologic target for post resuscitation immune dysfunction.

Myocardial Dysfunction and Shock after Cardiac Arrest

Postarrest myocardial dysfunction includes the development of low cardiac output or ventricular systolic or diastolic dysfunction after cardiac arrest. Impaired left ventricular systolic function is reported in nearly two-thirds of patients resuscitated after cardiac arrest. Hypotension and shock requiring vasopressor support are similarly common after cardiac arrest. Whereas shock requiring vasopressor support is consistently associated with an adverse outcome after cardiac arrest, the association between myocardial dysfunction and outcomes is less clear. Myocardial dysfunction and shock after cardiac arrest develop as the result of preexisting cardiac pathology with multiple superimposed insults from resuscitation. The pathophysiology involves cardiovascular ischemia/reperfusion injury and cardiovascular toxicity from excessive levels of inflammatory cytokine activation and catecholamines, among other contributing factors. Similar mechanisms occur in myocardial dysfunction after cardiopulmonary bypass, in sepsis, and in stress-induced cardiomyopathy. Hemodynamic stabilization after resuscitation from cardiac arrest involves restoration of preload, vasopressors to support arterial pressure, and inotropic support if needed to reverse the effects of myocardial dysfunction and improve systemic perfusion. Further research is needed to define the role of postarrest myocardial dysfunction on cardiac arrest outcomes and identify therapeutic strategies.

Shen-Fu Injection () alleviates post-resuscitation myocardial dysfunction by up-regulating expression of sarcoplasmic reticulum Ca(2+)-ATPase

OBJECTIVE

To compare the effect of Shen-Fu Injection (SFI) and epinephrine on the expression of sarcoplasmic reticulum Ca(2+) ATPase 2a (SERCA2a) in a pig model with post-resuscitation myocardial dysfunction.

METHODS

Ventricular fibrillation (VF) was electrically induced in Wu-zhi-shan miniature pigs. After 8 min of untreated VF and 2 min of cardiopulmonary resuscitation (CPR), all animals were randomly administered a bolus injection of saline placebo (SA group, n=10), SFI (0.8 mg/kg, SFI group, n=10) or epinephrine (20 μg/kg, EPI group, n=10). After 4 min of CPR, a 100-J shock was delivered. If the defibrillation attempt failed to attain restoration of spontaneous circulation (ROSC), manual chest compressions were rapidly resumed for a further 2 min followed by a second defibrillation attempt. Hemodynamic variables were recorded, and plasma concentrations of catecholamines were measured. Adenylate cyclase (AC), cyclic adenosine monophosphate (cAMP) and the expressions of β1-adrenoceptor (AR) and SERCA 2a were determined.

RESULTS

Cardiac output, left ventricular dp/dtmax and negative dp/dtmax were significantly higher in the SFI group than in the SA and EPI groups at 4 and 6 h after ROSC. The expression of β1-AR and SERCA2a at 24 h after ROSC were significantly higher in the SFI group than in the SA and EPI groups (P<0.05 or P<0.01).

CONCLUSIONS

The administration of epinephrine during CPR decreased the expression of SERCA2a and aggravated postresuscitation myocardial function (P<0.01). SFI attenuated post-resuscitation myocardial dysfunction, and the mechanism might be related to the up-regulation of SERCA2a expression.

Clinical assessment of Shenfu injection loading in the treatment of patients with exacerbation of chronic heart failure due to coronary heart disease: study protocol for a randomized controlled trial

Background

Acute exacerbation is a common cause of hospitalization in patients with chronic heart failure, and coronary heart disease is the most common cause. Shenfu injection, a Traditional Chinese Medicine injection, widely used in the adjuvant treatment of patients with acute exacerbation of chronic heart failure, shows some treatment effect in improving the symptoms and the quality of life, but it lacks the rigorous clinical evaluation of research reports. This paper describes the protocol for the clinical assessment of Shenfu injection loading in the treatment of patients with acute exacerbation of chronic heart failure.

Methods

This protocol adopts the design of a prospective, randomized, multicenter, blind imitation, placebo-controlled trial to assess the efficacy and safety of Shenfu injection loading in the treatment of patients with acute exacerbation of chronic heart failure due to coronary heart disease. The research will be carried out in 12 hospitals in China and is expected to enroll 160 inpatients with acute exacerbation of chronic heart failure due to coronary heart disease (yang and qi deficiency syndrome). On the basis of the conventional therapy of western medicine, patients will be randomized to either the treatment group (100 ml 5% glucose injection + 50 ml Shenfu injection) or the control group (150 ml 5% glucose injection) for 7 ± 1 days and follow-up for 28 ± 3 days. The primary outcomes are New York Heart Association cardiac function classification and Traditional Chinese Medicine syndromes. The secondary outcomes are left ventricular ejection fraction, brain natriuretic peptide level, Lee’s heart failure score, 6-minute walking distance, and the incidence and readmission rate of cardiovascular events (including the emergency rate due to acute exacerbation of chronic heart failure).

Discussion

This trial will assess the effect of loading Shenfu injection in the treatment of patients with acute exacerbation of chronic heart failure caused by coronary heart disease (yang-qi deficiency syndrome) on the symptoms and signs of heart failure, exercise tolerance, and other aspects, and observe its influence on the short-term prognosis with follow-up. The results of the study will provide clinical research evidence for application of Shenfu injection in the treatment.

Trial registration

This trial was registered on 26 December 2012 at the Chinese Clinical Trials Register (Identifier: ChiCTR-TRC-12002857).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0729-7) contains supplementary material, which is available to authorized users.

Simultaneous determination of aconite alkaloids and ginsenosides using online solid phase extraction hyphenated with polarity switching ultra-high performance liquid chromatography coupled with tandem mass spectrometry

Simultaneous determination of ten aconite alkaloids and thirteen ginsenosides using online solid phase extraction hyphenated with polarity switching ultra-high performance liquid chromatography coupled with tandem mass spectrometry.

Shenfu injection for intradialytic hypotension: a systematic review and meta-analysis

Objective. To evaluate the effectiveness and safety of Shenfu injection (SFI) for intradialytic hypotension (IDH). Methods. A systematic review of data sources published as of April 2014 was conducted. These included the Cochrane Central Register of Controlled Trials (2014 issue 4), Pubmed, Embase, CBM, CNKI, VIP, and Wangfang Data. Randomized controlled trials (RCTs) involving SFI for treatment and prevention of IDH were identified. Two researchers independently selected articles, extracted data, assessed quality, and cross checked the results. Revman 5.2 was used to analyze the results. Results. Eight RCTs were included. The meta-analysis indicated that compared with conventional therapies alone, SFI could elevate systolic blood pressure (SBP), increase the clinical effective rate, decrease the incidence of hypotension, increase serum albumin (ALB) levels, and reduce C-reactive protein (CRP) levels without serious adverse effects. GRADE Quality of Evidence. the quality of SBP, the effective rate, ALB, and CRP were low, and hypotension incidence and DBP were very low. Conclusions. SFI is more effective than conventional therapies for prevention and treatment of IDH. However, a clinical recommendation is not warranted due to the small number of studies included and low methodology quality. Multi-center and high-quality RCTs with large sample sizes are needed to provide stronger evidence.

Neuroprotective effect of Shenfu Injection () following cardiac arrest in pig correlates with improved mitochondrial function and cerebral glucose uptake

OBJECTIVE

To test whether Shenfu Injection (, SFI) might attenuate the impact of cerebral energy dysfunction after resuscitation in a pig model of cardiac arrest (CA).

METHODS

Thirty-four Wuzhishan miniature inbred pigs were randomly divided into three groups: the SFI group (n=12), the saline group (SA group, n=12), and the sham-operated group (sham group, n=10). Following successful return of spontaneous circulation (ROSC) from 8-min untreated ventricular fibrillation, animals received a continuous infusion of either SFI (0.2 mL/min) or saline for 6 h. Cerebral performance category score was evaluated at 24 and 48 h after ROSC, followed by positron emission tomography and computed tomography scans of cerebral glucose uptake. Surviving pigs were euthanized 48 h after ROSC, and the brains were removed for detecting mitochondrial function.

RESULTS

Compared with the SA group, SFI treatment produced a better neurologic outcome 48 h after ROSC (P<0.05). However, there was no significant difference of survival rate between the SA and SFI groups (83.3% vs. 81.8%, P>0.05). After ROSC, the SA group showed a decrease in the maximum standardized uptake value of different regions in the brain tissue, where SFI treatment can ameliorate these decreases (P<0.01 or P<0.05). Improved mitochondrial respiratory properties and higher mitochondrial membrane potential were also found following SFI treatment compared with the SA group at 48 h after ROSC (P<0.05 or P<0.01).

CONCLUSION

SFI treatment after resuscitation has significant neuroprotective effects against disruption of cerebral energy metabolism from CA by improving glucose uptake and by normalizing mitochondrial function.

The coronary dilation effect of shen fu injection was mediated through NO

OBJECTIVES

Shen Fu Injection (SF), which consisted of Red ginseng extraction injection (RG) and prepared aconite extraction injection (RA), is a traditional Chinese medicine mainly used for various cardiac diseases. This study is to analyse SF's effects on cardiac performance and coronary circulation. And the coronary dilating effect and mechanism of the above three injections were also explored.

METHODS

Mature male guinea pigs were used as our animal model. We employed two types of perfusion methods (constant pressure and constant flow) in vitro, using Langendorff heart preparations to observe the cardiac function and coronary response to SF (1/200). The coronary dilation effects of the above three injections (1/800, 1/400 and 1/200) were recorded at basal coronary resting tone and when coronary vessels were pre-contracted with a thromboxane A2 analogue (U46619), in the presence or the absence of the inhibitor of nitric oxide synthesis (L-NAME, 10-4 M), the blocker of Ca2+-activated potassium channel(TEA, 10-3 M), or the blocker of adenosine triphosphate (ATP)-sensitive potassium channel (glybenclamide) (10-5 M).

RESULTS

When perfused with constant pressure, SF significantly increased coronary flow, left ventricular developed pressure (LVDP) and the rate-pressure product (RPP). When perfused with constant flow, SF produced a significant reduction in the coronary perfusion pressure (CPP), LVDP and RPP. The coronary vasodilatation response of the above three injections can be reduced by L-NAME but was unaffected by TEA or glybenclamide when coronary vessels were pre-contracted with U46619 but not at resting tone. SF, RG and RA can all up-regulate eNOS expression in the human umbilical vein cells (EA.hy926).

CONCLUSION

We demonstrated that SF does not contribute to the inotropic change of myocardium whose improvement is due to alternation of coronary flow. The coronary dilation effect of SF was mediated through RG and RA, via promoting NO release.

Effects of Shenfu injection and its main components on the contraction of isolated rat thoracic aortic rings

Background and Purpose

Shenfu injection (SFI), derived from the ancient traditional Chinese medicine (Red Radix Ginseng and Radix Aconitum Carmichaeli), has been widely used in the clinical for the treatment of cardiovascular diseases for more than 20 years. The present study aims to investigate the effects of SFI and its main components on the contraction of isolated rat thoracic aorta rings and the potential mechanisms of this action.

Methodology/Principal Findings

The isolated rat thoracic aorta rings were initially treated with different concentrations of SFI, Hongshen injection (HSI, mainly containing ginsenoside) or Fupian injection (FPI, mainly containing aconite total alkaloids) separately. The control group was added an equal volume Krebs-Henseleit (K-H) solution. All three injections exhibited no obviously effects on the basal tension of the rings in the resting state. However, in the isolated thoracic aorta rings with intact endothelium, when the rings were first induced by 60 mM potassium chloride (KCl) or 1 µM norepinephrine (NE) to the maximal contraction and then treated with above injections, SFI and HSI significantly inhibited the vasoconstriction induced by KCl or NE. In addition, FPI has a tendency to inhibit KCl-induced vasoconstriction and facilitate NE-induced vasoconstriction, but no significant difference. None of them showed obvious effect on the endothelium denuded vessels. Moreover, this procedure was repeated after pre-incubation of nitric oxide synthase (NOS) inhibitor N^G-nitro- L-arginine methyl ester (L-NAME), which suppressed the vasorelaxation effect of SFI and HSI.

Conclusions and Implications

These results demonstrate that both SFI and HSI caused an apparent thoracic aorta relaxation by endothelium-dependent manner, which was associated with eNOS system, while FPI had no detectable vasodilator effect. This suggested that the ginsenoside from red Radix Ginseng may be the main active ingredient of SFI’s vasodilator effect.

Differences of postresuscitation myocardial dysfunction in ventricular fibrillation versus asphyxiation

PURPOSE

This study aims to characterize postresuscitation myocardial dysfunction in 2 porcine models of cardiac arrest (CA): ventricular fibrillation cardiac arrest (VFCA) and asphyxiation cardiac arrest (ACA).

METHODS

Thirty-two pigs were randomized into 2 groups. The VFCA group (n = 16) were subject to programed electrical stimulation, and the ACA group (n = 16) underwent endotracheal tube clamping to induce CA. Once induced, CA remained untreated for 8 minutes. Two minutes after initiation of cardiopulmonary resuscitation (CPR), defibrillation was attempted until return of spontaneous circulation (ROSC) was achieved or animals died.

RESULTS

Return of spontaneous circulation was 100% successful in VFCA and 50% successful in ACA. Cardiopulmonary resuscitation duration in VFCA was about half as short as in ACA. The survival time of VFCA was significantly longer than that of ACA. Ventricular fibrillation cardiac arrest had better mean arterial pressure, cardiac output, and left ventricular ± dp/dt(max) after ROSC than ACA. Echocardiography revealed significantly lower left ventricular ejection fraction in ACA than in VFCA. Myocardial perfusion imaging using single-photon emission computed tomography demonstrated that myocardial injuries after ACA were more severe and widespread than after VFCA. Under a transmission electron microscope, the overall heart morphologic structure and the mitochondrial crista structure were less severely injured in the VFCA group than in the ACA group. Moreover, the percentage of apoptotic cardiomyocytes was higher in ACA than in VFCA.

CONCLUSIONS

Compared with VFCA, ACA causes more severe cardiac dysfunction associated with less successful resuscitation and shorter survival time.

The roles of traditional chinese medicine: shen-fu injection on the postresuscitation care bundle

Survival rates following in-hospital and out-of-hospital cardiac arrests remain disappointingly low. Organ injury caused by ischemia and hypoxia during prolonged cardiac arrest is compounded by reperfusion injury that occurs when a spontaneous circulation is restored. A bundle of procedures, which may need to be administered simultaneously, is required. The procedures include prompt identification and treatment of the cause of cardiac arrest, as well as a definitive airway and ventilation together. Additional benefit is possible with appropriate forms of early goal-directed therapy and achieving therapeutic hypothermia within the first few hours, followed by gradual rewarming and ensuring glycaemic control to be within a range of 6 to 10 mmol/L. All these would be important and need to be continued for at least 24 hours. Previous studies have showed that the effects of Shen-Fu injection (SFI) are based on aconitine properties, supplemented by ginsenoside, which can scavenge free radicals, improve energy metabolism, inhibit inflammatory mediators, suppress cell apoptosis, and alleviate mitochondrial damage. SFI, like many other complex prescriptions of traditional Chinese medicine, was also found to be more effective than any of its ingredient used separately in vivo. As the postresuscitation care bundle is known to be, the present paper focuses on the role of SFI played on the postresuscitation care bundle.

Therapeutic effects of Shenfu Injection on post-cardiac arrest syndrome

Survival rates after cardiac arrest have not changed substantially over the past 5 decades. Postcardiac arrest (CA) syndrome (PCAS) is the primary reason for the high mortality rate after successful restoration of spontaneous circulation (ROSC). Intravenous administration of Shenfu Injection (, SFI) may attenuate post-CA myocardial dysfunction and cerebral injury, inhibit systemic ischemia/reperfusion responses, and treat underlying diseases. In this article, we reviewed the therapeutic effects of SFI in PCAS. SFI might be useful in the treatment of PCAS, incorporating the multi-link and multi-target advantages of Chinese medicine into PCAS management. Further experimental and clinical research to verify the therapeutic effects of SFI in PCAS is required.

Ginseng-Aconite Decoction elicits a positive inotropic effect via the reverse mode Na+/Ca2+ exchanger in beating rabbit atria

ETHNOPHARMACOLOGICAL RELEVANCE

Ginseng-Aconite Decoction (GAD), a traditional oriental medicine composed of Panax ginseng C.A. Mey. (Araliaceae) and Aconitum carmichaeli Debx. (Ranunculaceae) has been used as treatment for cardiovascular diseases from Song Dynasty of China. The purpose of the present study was to elucidate the possible mechanisms of GAD-induced positive inotropic effect.

MATERIAL AND METHODS

GAD-induced changes in atrial dynamics and cAMP efflux were determined in isolated perfused beating rabbit atria.

RESULTS

GAD significantly increased atrial dynamics such as stroke volume, pulse pressure and augmented cAMP efflux in beating rabbit atria. The inotropic effect was significantly attenuated by pre-treatment with KB-R7943, a reverse mode Na(+)/Ca(2+) exchanger blocker. The GAD-induced increase in atrial dynamics was also markedly inhibited by staurosporine, a non-selective protein kinase inhibitor, and partly blocked by KT5720, a selective PKA inhibitor. The effect of GAD on atrial dynamics was not altered by pre-treatment with propranolol, a β-adrenergic receptor inhibitor, or diltiazem, an L-type Ca(2+)channel blocker. The phosphodiesterase (PDE) inhibitor 3-isobutyl-1-methylxanthine (IBMX) failed to modulate the GAD-induced increase in atrial dynamics, but markedly attenuated cAMP efflux in the beating atria.

CONCLUSION

These results suggest that the GAD-induced positive inotropic effect in beating rabbit atria may be attributable to stimulation of the reverse mode Na(+)/Ca(2+) exchanger, while PKA activity would, at least in part, be participated in the course.

Effect of mild hypothermia on the coagulation-fibrinolysis system and physiological anticoagulants after cardiopulmonary resuscitation in a porcine model

The aim of this study was to evaluate the effect of mild hypothermia on the coagulation-fibrinolysis system and physiological anticoagulants after cardiopulmonary resuscitation (CPR). A total of 20 male Wuzhishan miniature pigs underwent 8 min of untreated ventricular fibrillation and CPR. Of these, 16 were successfully resuscitated and were randomized into the mild hypothermia group (MH, n = 8) or the control normothermia group (CN, n = 8). Mild hypothermia (33°C) was induced intravascularly, and this temperature was maintained for 12 h before pigs were actively rewarmed. The CN group received normothermic post-cardiac arrest (CA) care for 72 h. Four animals were in the sham operation group (SO). Blood samples were taken at baseline, and 0.5, 6, 12, 24, and 72 h after ROSC. Whole-body mild hypothermia impaired blood coagulation during cooling, but attenuated blood coagulation impairment at 72 h after ROSC. Mild hypothermia also increased serum levels of physiological anticoagulants, such as PRO C and AT-III during cooling and after rewarming, decreased EPCR and TFPI levels during cooling but not after rewarming, and inhibited fibrinolysis and platelet activation during cooling and after rewarming. Finally, mild hypothermia did not affect coagulation-fibrinolysis, physiological anticoagulants, or platelet activation during rewarming. Thus, our findings indicate that mild hypothermia exerted an anticoagulant effect during cooling, which may have inhibitory effects on microthrombus formation. Furthermore, mild hypothermia inhibited fibrinolysis and platelet activation during cooling and attenuated blood coagulation impairment after rewarming. Slow rewarming had no obvious adverse effects on blood coagulation.

Shen-Fu injection reduces impaired myocardial β-adrenergic receptor signaling after cardiopulmonary resuscitation

BACKGROUND

Post-resuscitation myocardial dysfunction has been implicated as a major cause of fatal outcome in patients who survive initially successful cardiopulmonary resuscitation (CPR). In our previous study, we found that impaired myocardial β-adrenergic receptor (AR) signaling is a key mechanism in post-resuscitation myocardial dysfunction and Shen-Fu injection (SFI) can attenuate post-resuscitation myocardial dysfunction. However, whether SFI can prevent impaired post-resuscitation myocardial β-AR signaling is not yet known. In this study, we investigated the effect of SFI on impaired myocardial β-AR signaling occurring post-resuscitation in a porcine model of cardiac arrest.

METHODS

Ventricular fibrillation was induced electrically in anesthetized male landrace domestic pigs. After 4 minutes of untreated ventricular fibrillation, cardiopulmonary resuscitation was initiated. Sixteen successfully resuscitated pigs were randomized to receive a continuous infusion of either SFI (0.5 ml/min; n = 8) or saline (placebo; n = 8) for 6 hours, beginning 15 minutes after the return of spontaneous circulation (ROSC). Hemodynamic and echocardiographic data were recorded. β-AR signaling was assessed at 6 hours after the intervention by measuring myocardial adenylate cyclase activity, β-AR density and β-AR kinase expression.

RESULTS

Treatment with SFI produced better maximum rate of left ventricular pressure increase (dp/dt(max)) and maximum rate of left ventricular pressure decline (-dp/dt(max)), cardiac output, and ejection fraction after ROSC. SFI treatment was also associated with lower myocardial β-adrenergic receptor kinase expression, whereas basal and isoproterenol-stimulated adenylate cyclase activity and the total β-AR density were significantly increased in the SFI group when compared with the placebo group.

CONCLUSION

SFI attenuated post-resuscitation myocardial dysfunction by preventing impaired myocardial β-AR signaling after CPR.

Shen-fu injection reduces postresuscitation myocardial dysfunction in a porcine model of cardiac arrest by modulating apoptosis

Shen-Fu injection (SFI) following cardiac arrest exhibits cardioprotective effects, but its effect on myocardial dysfunction, a critical issue following resuscitation, is unclear. This study sought to examine whether SFI reduces postresuscitation myocardial dysfunction in a porcine model of cardiac arrest by modulating apoptosis. After 8 min of untreated ventricular fibrillation and 2 min of basic life support, 24 pigs were randomized divided into three groups, which received central venous injection of either Shen-Fu (SFI group; 1.0 mL/kg), epinephrine (EP group; 0.02 mg/kg), or saline (SA group). After successful return of spontaneous circulation (ROSC), hemodynamic status and blood samples were obtained at 0, 30, 120, and 360 min after ROSC. Surviving pigs were killed at 24 h after ROSC, and the hearts were removed for analysis by electron microscopy, Western blotting, quantitative real-time polymerase chain reaction, and TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling) assay. Compared with the EP and SA groups, animals treated with SFI had improved left ventricular function (P < 0.05), lower troponin T levels (P < 0.01), and increased tissue perfusion and oxygen metabolism (P < 0.05). Shen-Fu injection was associated with a reduction in (i) Bcl-2, Bax, and caspase 3 protein expression (P < 0.05); (ii) caspase 3 mRNA upregulation; and (iii) apoptosis, compared with the EP and SA groups. Caspase 3-mediated apoptosis occurs following myocardial injury after cardiopulmonary resuscitation in pigs. Shen-Fu injection decreased myocardial injury; improved myocardial ultrastructure; inhibited Bcl-2, Bax, and caspase 3 expression; and reduced myocardial apoptosis. Therefore, SFI could significantly attenuate postresuscitation myocardial dysfunction by modulating apoptosis.

Chinese medicine shenfu injection for heart failure: a systematic review and meta-analysis

Objective. Heart failure (HF) is a global public health problem. Early literature studies manifested that Shenfu injection (SFI) is one of the most commonly used traditional Chinese patent medicine for HF in China. This article intended to systematically evaluate the efficacy and safety of SFI for HF. Methods. An extensive search was performed within 6 English and Chinese electronic database up to November 2011. Ninety-nine randomized controlled trails (RCTs) were collected, irrespective of languages. Two authors extracted data and assessed the trial quality independently. RevMan 5.0.2 was used for data analysis. Results. Compared with routine treatment and/or device support, SFI combined with routine treatment and/or device support showed better effect on clinical effect rate, mortality, heart rate, NT-proBNP and 6-minute walk distance. Results in ultrasonic cardiography also showed that SFI combined with routine treatment improved heart function of HF patients. There were no significant difference in blood pressure between SFI and routine treatment groups. Adverse events were reported in thirteen trails with thirteen specific symptoms, while no serious adverse effect was reported. Conclusion. SFI appear to be effective for treating HF. However, further rigorously designed RCTs are warranted because of insufficient methodological rigor in the majority of included trials.