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Cardiomyocyte apoptosis in autoimmune cardiomyopathy: mediated via endoplasmic reticulum stress and exaggerated by norepinephrine

Cardiology Division, Department of Medicine, and Department of Pharmacology and Physiology, University of Rochester Medical Center, Rochester, New York; and Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska University Hospital, Göteborg, Sweden

Submitted 18 December 2006 ; accepted in final form 29 May 2007

Evidence suggests that the autoimmune cardiomyopathy produced by a peptide corresponding to the sequence of the second extracellular loop of the ₁-adrenergic receptor (₁-EC_II) is mediated via a biologically active anti-₁-EC_II antibody, but the mechanism linking the antibody to myocyte apoptosis and cardiac dysfunction has not been well elucidated. Since the ₁-EC_II autoantibody is a partial ₁-agonist, we speculate that the cardiomyopathy is produced by the ₁-receptor-mediated stimulation of the CaMKII-p38 MAPK-ATF6 signaling pathway and endoplasmic reticulum (ER) stress, and that excess norepinephrine (NE) exaggerates the cardiomyopathy. Rabbits were randomized to receive ₁-EC_II immunization, sham immunization, NE pellet, or ₁-EC_II immunization plus NE pellet for 6 mo. Heart function was measured by echocardiography and catheterization. Myocyte apoptosis was determined by terminal deoxytransferase-mediated dUTP nick-end labeling and caspase-3 activity, whereas CaMKII, MAPK family (JNK, p38, ERK), and ER stress signals (ATF6, GRP78, CHOP, caspase-12) were measured by Western blot, immunohistochemistry, and kinase activity assay. ₁-EC_II immunization produced progressive LV dilation, systolic dysfunction, and myocyte apoptosis. These changes were associated with activation of GRP78 and CHOP and increased cleavage of caspase-12, as well as increased CaMKII activity, increased phosphorylation of p38 MAPK, and nucleus translocation of cleaved ATF6. NE pellet produced additive effects. In addition, KN-93 and SB 203580 abolished the induction of ER stress and cell apoptosis produced by the ₁-EC_II antibody in cultured neonatal cardiomyocytes. Thus ER stress occurs in autoimmune cardiomyopathy induced by ₁-EC_II peptide, and this is enhanced by increased NE and caused by activation of the ₁-adrenergic receptor-coupled CaMKII, p38 MAPK, and ATF6 pathway.

cardiomyocytes; signal transduction

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