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Effect of Arginase Inhibition on Ischemia-Reperfusion Injury in Patients with Coronary Artery Disease with and Without Diabetes Mellitus

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Effect of Arginase Inhibition on Ischemia-Reperfusion Injury in Patients with Coronary Artery Disease with and Without Diabetes Mellitus Effect of Arginase Inhibition on Ischemia-Reperfusion Injury in Patients with Coronary Artery Disease with and without Diabetes Mellitus Oskar Ko¨ vamees*, Alexey Shemyakin, John Pernow Department of Medicine, Karolinska Institutet, Stockholm, Sweden Abstract Background: Arginase competes with nitric oxide synthase for their common substrate L-arginine. Up-regulation of arginase in coronary artery disease (CAD) and diabetes mellitus may reduce nitric oxide bioavailability contributing to endothelial dysfunction and ischemia-reperfusion injury. Arginase inhibition reduces infarct size in animal models. Therefore the aim of the current study was to investigate if arginase inhibition protects from endothelial dysfunction induced by ischemia-reperfusion in patients with CAD with or without type 2 diabetes (Clinical trial registration number: NCT02009527). Methods: Male patients with CAD (n = 12) or CAD + type 2 diabetes (n = 12), were included in this cross-over study with blinded evaluation. Endothelium-dependent vasodilatation was assessed by flow-mediated dilatation (FMD) of the radial artery before and after 20 min ischemia-reperfusion during intra-arterial infusion of the arginase inhibitor (Nv-hydroxy-nor- L-arginine, 0.1 mg/min) or saline. Results: The forearm ischemia-reperfusion was well tolerated. Endothelium-independent vasodilatation was assessed by sublingual nitroglycerin. Ischemia-reperfusion decreased FMD in patients with CAD from 12.765.2% to 7.964.0% during saline administration (P,0.05). Nv-hydroxy-nor-L-arginine administration prevented the decrease in FMD in the CAD group (10.364.3% at baseline vs. 11.563.6% at reperfusion). Ischemia-reperfusion did not significantly reduce FMD in patients with CAD + type 2 diabetes. However, FMD at reperfusion was higher following nor-NOHA than following saline administration in both groups (P,0.01). Endothelium-independent vasodilatation did not differ between the occasions. Conclusions: Inhibition of arginase protects against endothelial dysfunction caused by ischemia-reperfusion in patients with CAD. Arginase inhibition may thereby be a promising therapeutic strategy in the treatment of ischemia-reperfusion injury. Citation: Ko¨vamees O, Shemyakin A, Pernow J (2014) Effect of Arginase Inhibition on Ischemia-Reperfusion Injury in Patients with Coronary Artery Disease with and without Diabetes Mellitus. PLoS ONE 9(7): e103260. doi:10.1371/journal.pone.0103260 Editor: Ferenc Gallyas. Jr, University of Pecs Medical School, Hungary Received February 21, 2014; Accepted June 30, 2014; Published July 29, 2014 Copyright: ß 2014 Ko¨vamees et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This study was supported by the European Foundation for the Study of Diabetes, Swedish Research Council Medicine (10857), the Swedish Heart and Lung Foundation, the Stockholm County Council (ALF), Karolinska Institutet/Stockholm County Council Strategic Cardiovascular Programme, Novo Nordisk Foundation and Gustav V and Queen Victoria Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * Email: [email protected] Introduction species [6]. NO may in addition prevent calcium release from the sarcoplasmatic reticulum and activation of mitochondrial perme- Current treatment strategy for ST-elevation myocardial infarc- ability transition pores which is a central process in reperfusion tion involves rapid reperfusion of the occluded coronary artery by injury [2]. Accordingly, restoration of NO bioavailability has been percutaneous coronary intervention or thrombolysis to limit shown to reduce the extent of reperfusion injury in experimental infarct size [1]. However, rapid restoration of blood flow to the studies via a mechanism related to anti-inflammatory effects, ischemic tissue itself may cause additional damage to the scavenging of reactive oxygen species and preservation of myocardium and coronary vasculature referred to as reperfusion mitochondria function [6–8]. injury [2]. The mechanism(s) behind reperfusion injury is complex Arginase is a metalloprotease that has emerged as an important and include oxidative stress, intracellular calcium ion overload, regulator of NO production throughout the cardiovascular system inflammation and opening of ion channels in the mitochondrion [9]. A delicate balance exists between arginase and NO synthase [3]. Endothelial dysfunction, characterized by reduced bioavail- (NOS) by their competition for the common substrate L-arginine ability of nitric oxide (NO), is known to be central for the [9]. Up-regulation of arginase leads to impaired NO production, development of reperfusion injury [4,5]. The protection mediated increased levels of reactive oxygen species and induction of by NO in the setting of ischemia-reperfusion include among endothelial dysfunction [10]. Arginase has therefore been suggest- several effects increased microvascular perfusion due to vasodila- ed to play an important role in reperfusion injury [11]. tation, anti-inflammatory effects and scavenging of reactive oxygen Accordingly, inhibition of arginase markedly reduces infarct size PLOS ONE | www.plosone.org 1 July 2014 | Volume 9 | Issue 7 | e103260 Arginase in Ischemia-Reperfusion Injury in animal models of ischemia-reperfusion via a mechanism was used for determination of flow-mediated dilatation (FMD) involving preserved bioavailability of NO [12–14]. The role of since the brachial artery was catheterized for study drug infusions arginase in the development of ischemia-reperfusion injury in (see below). A blood pressure cuff was placed around the upper patients with coronary artery disease (CAD) has previously not part of the forearm, which was inflated to 30 mmHg above systolic been investigated, however. Based on the experimental data pressure or 200 mmHg for 5 min. The diameter of the radial described above, we hypothesized that arginase is of pathophys- artery was continuously recorded for 3 min during hyperemia iological importance in ischemia-reperfusion and that inhibition of induced by deflation of the cuff. The three frames displaying arginase activity will prevent the development of ischemia- maximum dilatation at end-diastole (triggered from the ECG) reperfusion injury in patients with CAD. were used to calculate a mean diameter [17]. All images were We have recently demonstrated that arginase inhibition analyzed with Brachial analyzer (Medical Imaging Applications, improves basal endothelial function in patients with CAD with Iowa City, IA, USA). FMD was calculated as a percentage or without concomitant type 2 diabetes mellitus [15]. The increase in diameter from baseline diameter according to the improvement in endothelial function was greater in patients with following formula: diameter following cuff deflation-baseline diabetes than in patients without diabetes suggesting that the role diameter/baseline diameter x 100. The coefficient of variation is of arginase may be particularly important in patients with type 2 18% [18]. diabetes. Available data suggest that treatment strategies to prevent ischemia-reperfusion injury may be less effective in the Study protocol presence of type 2 diabetes [16]. Accordingly, it appears to be of The design of the study was randomized cross-over with blinded importance to develop effective therapies that improves endothe- evaluation. One single operator who was unaware of the lial function following ischemia-reperfusion in patients with a intervention performed all FMD registrations, analyses and common co-morbidity such as type 2 diabetes. Therefore, we calculations. Subjects performed the protocol twice, on one investigated the effect of local arginase inhibition on endothelial occasion active treatment was administrated and on the other dysfunction induced by ischemia- reperfusion in the forearm of placebo (saline). The order of how the subjects received patients with CAD with and without type 2 diabetes. intervention was randomly assigned by drawing one of two numbers written on two pieces of paper. The experiment was Methods implemented in a dimly lit room in a calm environment. The Subjects subject did not take their morning medication and were instructed Patients were recruited from the coronary angiography and to refrain from caffeine-containing drinks or nicotine product on angioplasty registry at Karolinska University Hospital between the day of the study. A light standardized breakfast was provided December 2011 and June 2013. One group (n = 12) consisted of to the subjects before the experiments. A percutaneous catheter patients with CAD and the other group (n = 12) consisted of was introduced in the brachial artery of the non-dominant arm patients with CAD and type 2 diabetes mellitus (CAD+DM). (left arm for all subjects) in the proximal direction following local Patients with CAD defined as previous myocardial infarction or as infiltration of anesthesia with 2 ml carbocaine (10 mg/ml, $50% stenosis in one or more of the coronary arteries during AstraZeneca, So¨derta¨lje, Sweden). The arm was then fixed with angiography treated with percutaneous coronary intervention or a vacuum cushion to prevent excessive movement during the coronary artery bypass grafting
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