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-adrenoceptor mechanisms by
H2O2
Institute of Cardiovascular Sciences, St. Boniface General Hospital Research Centre, and Department of Physiology, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada R2H 2A6
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ABSTRACT |
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From the role of oxidative stress in cardiac
dysfunction, we investigated the effect of
H2O2,
an activated species of oxygen, on
-adrenoceptors, G proteins, and
adenylyl cyclase activities. Rat heart membranes were incubated with
different concentrations of
H2O2
before the biochemical parameters were measured. Both the affinity and
density of
1-adrenoceptors were
decreased, whereas the density of the
2-adrenoceptors was decreased
and the affinity was increased by 1 mM
H2O2.
Time- and concentration-dependent biphasic changes in adenylyl cyclase
activities in the absence or presence of isoproterenol were observed
when membranes were incubated with
H2O2;
however, activation of the enzyme by isoproterenol was increased or
unaltered. The adenylyl cyclase activities in the absence or presence
of forskolin, NaF, and Gpp(NH)p were depressed by
H2O2.
Catalase alone or in combination with mannitol was able to
significantly decrease the magnitude of alterations due to H2O2.
The cholera toxin-stimulated adenylyl cyclase activity and ADP ribose
labeling of Gs proteins were
decreased by treatment with 1 mM
H2O2,
whereas Gi protein activities, as
reflected by pertussis toxin-stimulation of adenylyl cyclase and ADP
ribosylation, were unaltered. The
Gs and
Gi protein immunoreactivities,
estimated by labeling with respective antibodies, indicate a decrease
in binding to the 45-kDa band of
Gs protein, whereas no change in the binding of antibodies to the 52-kDa band of
Gs protein or the 40-kDa subunit
of Gi protein was evident when the
membranes were treated with 1 mM
H2O2.
These results suggest that
H2O2
in high concentrations may attenuate the
-adrenoceptor-linked signal transduction in the heart by changing the functions of
Gs proteins and the catalytic
subunit of the adenylyl cyclase enzyme.
cardiac G proteins; cardiac adenylyl cyclase; oxidative stress
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INTRODUCTION |
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SEVERAL STUDIES have reported an increase in the
formation of
H2O2
under different pathological conditions, including
ischemia-reperfusion in the heart (15, 16, 29). Such an
increase in the production of this active species of oxygen has been
shown to be due to dismutation of the superoxide radicals, generation
in the mitochondria, and activation of the leukocytes (15, 16, 26). In
fact,
H2O2 has been suggested to be involved in promoting cardiac dysfunction and
injury by inducing intracellular
Ca2+ overload due to modification
of the sarcolemmal and sarcoplasmic reticular
Ca2+-handling mechanisms (8,
10-12, 26). Because the
-adrenoceptor, G proteins, and adenylyl
cyclase system are known to regulate the intracellular concentration of
Ca2+ and cardiac function (2, 3,
30), it is likely that this signal transduction pathway may be affected
by
H2O2.
In this regard, some investigators have shown a decrease in the
affinity without any change in the density of
-adrenoceptors (13,
18), whereas others have reported both an increase and a decrease in
the density of
-adrenoceptors when cardiac membranes were treated
with
H2O2 (7). Likewise,
H2O2
was observed to decrease and increase the adenylyl cyclase activities
in cardiac membranes (18) and vascular smooth muscle cells (31),
respectively. Although
H2O2
has been reported to exert no effect on G proteins in cardiac membranes and vascular smooth muscle cells (18, 31), the results are of a
preliminary nature. From the conflicting and inconclusive results
regarding the effects of
H2O2
on the
-adrenoceptor, G proteins, and adenylyl cyclase system as
well as the lack of information concerning the action of
H2O2
on cardiac
1- and
2-adrenoceptors, this study was
undertaken to provide detailed information concerning changes in the
-adrenoceptor linked signal transduction mechanism due to
H2O2.
For this purpose, alterations in
1- and
2-adrenoceptors, adenylyl
cyclase activities, and Gi as well
as Gs protein functions were
monitored when rat heart membranes were treated with
H2O2.
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METHODS |
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Treatment of membranes with H2O2. Cardiac membranes were prepared from the nonperfused rat heart according to the method described earlier (4). Unless otherwise indicated, aliquots of membrane were incubated with different concentrations of H2O2 for 10 min at 30°C. Membranes incubated without any additions served as controls. Catalase and mannitol, when used as scavengers, were at the concentration of 10 µg/ml and 20 mM, respectively. Membranes treated with or without H2O2 were thoroughly washed and resuspended in 50 mM tris(hydroxymethyl)aminomethane (Tris) · HCl (pH 7.4) before their use for different assays.
-Adrenergic receptor binding.
To determine
1- and
2-adrenergic receptor binding
(24), aliquots of control or
H2O2-treated
membrane preparations (0.1 mg/ml) were incubated for 60 min at 37°C
with various concentrations (5-400 pM) of
[125I]iodocyanopindolol
(125I-CYP, 2,200 Ci/mmol) in the
absence or presence of either 100 µM CGP-20712A (a highly selective
1-antagonist) or 100 µM
ICI-118551 (a highly selective
2-antagonist). Incubations were
stopped by rapid vacuum filtration through Whatman GF/C filters, and
the radioactivity in the absence or presence of
-adrenoceptor
antagonists was measured to determine the total and nonspecific
receptor binding. Specific binding to
1-receptors was calculated as
the difference between 125I-CYP
binding values in the absence (total binding) and presence (nonspecific
binding) of CGP-20712A, whereas the
2-receptor specific binding was
the difference between 125I-CYP
binding values in the absence (total binding) and presence (nonspecific
binding) of ICI-118551. The values for maximal binding (Bmax) and dissociation constant
(Kd) were
calculated from the Scatchard plot analysis of the binding data
according to the interactive LIGAND program of Munson and Rodbard (20).
Determination of adenylyl cyclase activity.
Adenylyl cyclase activity was determined by measuring
32P-labeled adenosine
3',5'-cyclic monophosphate (cAMP) formation from [
-32P]ATP as
described previously (24). Unless otherwise indicated the incubation
assay medium contained 50 mM glycylglycine (pH 7.5), 0.5 mM MgATP,
[32P]ATP (1-1.5 × 106 counts/min), 5 mM
MgCl2 (in excess of the ATP
concentration), 100 mM NaCl, 0.5 mM cAMP, 0.1 mM ethylene
glycol-bis(
-aminoethyl ether)-N,N,N',N'-tetraacetic
acid (EGTA), 0.5 mM 3-isobutyl-1-methylxanthine, 10 U/ml adenosine
deaminase, and an ATP-regenerating system comprising 2 mM creatine
phosphate and 0.1 mg creatine kinase/ml in a final volume of 200 µl.
Incubations were initiated by the addition of membranes (30-70
µg) to the reaction mixture, which had been equilibrated for 3 min at
37°C. The incubation time was 10 min at 37°C, and the reaction
was terminated by the addition of 0.6 ml of 120 mM zinc acetate
containing 0.5 mM unlabeled cAMP. The unlabeled cAMP served to monitor
recovery of [32P]cAMP
by measuring absorbance at 259 nm. The formation of cAMP was determined
by coprecipitation of other nucleotides with
ZnCO3 by the addition of 0.5 ml of
144 mM
Na2CO3
and subsequent chromatography by a double-column system as described by
Salomon et al. (27). Under the assay conditions used, the adenylyl
cyclase activity was linear with respect to protein concentration and
time of incubation. To study the effects of pertussis toxin and cholera
toxin on adenylyl cyclase activity (determination of the functional
activities of G proteins), membrane preparations were treated with or
without toxins for 60 min at 30°C in the same reaction mixture as
that used for ADP ribosylation except that 10 mM NAD was used in place of [
-32P]NAD (24).
The membranes were washed two to three times with Tris buffer and
finally suspended in the same buffer for the estimation of adenylyl
cyclase activity.
Toxin-catalyzed ADP ribosylation.
Cholera toxin catalyzed- and pertussis toxin catalyzed-ADP ribosylation
of Gs and
Gi proteins, respectively, were
performed according to the method described previously (24). In brief, 50 µg of the control and
H2O2-treated
membrane proteins were incubated for 60 min at 30°C in 100 µl of
100 mM Tris · HCl (pH 7.4) containing 1 mM EDTA, 1 mM
EGTA, 5 mM MgCl2, 1 mM ATP, 0.1 mM
GTP, 10 mM thymidine, 2 µM
[32P]NAD (2 Ci/mmol),
and activated pertussis toxin (5 µg/ml) for the determination of
Gi protein activity. The
Gs protein activity was assayed in
an analogous fashion; the membrane protein was incubated for 90 min at
30°C in 100 mM Tris · HCl (pH 7.4) containing 1 mM EDTA, 1 mM EGTA, 5 mM MgCl2, 1 mM ATP, 10 mM thymidine, 0.1 mM GTP, 10 mM arginine, 1 mM
NADP+, 2 µM
[32P]NAD (20 Ci/mmol),
and activated cholera toxin (20 µg/ml). Both toxins were activated by
incubation in 50 mM dithiothreitol for 30 min at 30°C. The samples
were applied to a 12% sodium dodecyl sulfate-polyacrylamide gel
according to the method of Laemmli (17). The gels were dried and
subjected to autoradiography using Kodak X-AR5 film at
70°C
for 24-72 h. An imaging densitometer (Bio-Rad Laboratories,
Mississauga, Canada) was used to quantitate the
Gs and
Gi proteins in control and
experimental preparations.
Electrophoresis and immunoblot assay.
The Gs and
Gi proteins were quantified by an
immunoblotting method described earlier (24). Control and
H2O2-treated
membranes were suspended in 50 µl
H2O and 50 µl sample buffer
[6.4 M urea, 17 mM Tris · HCl, 19.5 mM glycine
(pH 8.6), 10 mM dithiothreitol, 10 mM EGTA, 1 mM EDTA, 5 mM NaF, 1 mM
phenylmethylsulfonyl fluoride, and 0.4% bromphenol blue] and
then denatured by boiling for 3 min. The proteins were
resolved in sodium dodecyl sulfate-12% polyacrylamide gel (17) and
then electroblotted to nitrocellulose sheets by employing a 25 mM
Na2HPO4
transfer buffer. After transfer, the nitrocellulose sheets were shaken
for ~2 h in blocking buffer, which contained 10 mM Tris-buffered
saline (TBS), 5% fat-free powdered milk, and 0.1% Tween 20. The blots
were then incubated at 4°C for 14 h with specific antisera
[AS/7 specific for Gi
protein and RM/1 specific for
Gs
protein (1:3,000)] in
TBS and then washed twice for 10 min each with 0.1% Tween 20 and TBS alternately. The antigen-antibody complexes were detected by
chemiluminescent detection, whereby the nitrocellulose sheets were
dipped in luminol substrate solution (Amersham, Oakville, Canada). To
visualize the bands, chemilumigrams were developed on Hyperfilm-ECL;
normal exposure times ranged from 30 s to 1 min. The specific bands for Gi
and
Gs
proteins in control and
experimental preparations were quantified by using the Bio-Rad imaging
densitometer previously indicated.
Statistical analysis of the data. All results are expressed as means ± SE and were analyzed statistically by using Student's t-test. In some experiments as indicated in the text, Duncan's post hoc test for multiple comparisons following F score on an analysis of variance was also used to determine the difference between mean values. P < 0.05 was considered to reflect a significant difference between the control and experimental preparations.
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RESULTS |
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Adenylyl cyclase activity.
The adenylyl cyclase activity in membrane preparations treated in vitro
for 10 min with 1 mM
H2O2
was decreased significantly compared with control (Table
1); this was the case whether the activity
was measured in the absence (basal) or presence of various stimulants
such as forskolin, NaF, or 5'-guanylylimidodiphosphate (Gpp(NH)p).
However, when the results were expressed as percentage of values in the
absence of stimulants, the activation of adenylyl cyclase by forskolin,
NaF, or Gpp(NH)p was higher in the
H2O2-treated preparations (Table 1). These alterations due to
H2O2
were markedly attenuated in the presence of catalase plus mannitol
(Table 1). To show whether the catalytic site of adenylyl cyclase is
affected by 1 mM
H2O2
treatment, the enzyme activity was measured in a medium containing 1 mM
Mn2+ instead of
Mg2+. The adenylyl activity under
this experimental condition was also depressed in the
H2O2-treated
preparations in comparison to the control values (10.5 ± 1.5 vs.
43.0 ± 2.2 pmol cAMP · mg protein
1 · min
1;
n = 4 for each observation). In
another set of experiments, the effect of
H2O2
on the cardiac adenylyl cyclase activity in the presence of different
concentrations of isoproterenol was examined. The data in Fig.
1A show
a marked reduction in the isoproterenol-stimulated adenylyl cyclase
activity on treatment with 1 mM
H2O2.
However, the activation of adenylyl cyclase in the
H2O2-treated
preparations by different concentrations of isoproterenol
(10
10 to
10
3 M) was greater than the
respective control values (Fig. 1B). These results indicate that while the adenylyl cyclase activities in
the absence or presence of different stimulants were depressed when
membranes were treated with a high concentration (1 mM) of H2O2,
the responsiveness of the enzyme to the stimulants was increased.
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-Adrenergic receptors.
To show whether
-adrenergic receptors were altered on treatment with
H2O2,
the specific binding of 125I-CYP
to both
1- and
2-adrenoceptors was studied
in cardiac membranes. Figure 4 shows the
specific binding data for
1-adrenoceptors as well as
Scatchard plot analysis of
125I-CYP binding to
1-receptors in control and 1 mM
H2O2-treated membranes. Both the density
(Bmax) and affinity
(1/Kd) of the
1-receptors were significantly
reduced in the
H2O2-treated
membranes compared with the control values (Fig. 4 and Table
3). Although Scatchard plot analysis of the
data on 125I-CYP binding to
2-adrenoceptors alsorevealed a
depression in the density of this receptor subtype, an increase in the
affinity of
2-adrenoceptors was
evident in the
H2O2-treated
membranes (Table 3). The presence of catalase alone or in combination
with mannitol in the incubation mixture was able to greatly prevent the
H2O2-induced
alteration in the
1- and
2-adrenoceptors (Table 3). It
should be noted that treatment of membranes with low concentrations of
H2O2
(0.2 mM) for 10 min had no effect on the density or affinity of
1- and
2-adrenoceptors because these
values (n = 2) were not different from
the control values shown in Table 3.
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G protein activities and contents. Adenylyl cyclase activity due to changes in the G protein function was determined in the presence of cholera toxin, an activator of Gs protein, or pertussis toxin, an inhibitor of Gi protein, and the results are shown in Fig. 5. The data indicate that whereas the cholera toxin-induced increase in adenylyl cyclase was depressed in the 1 mM H2O2-treated membranes, the pertussis toxin-induced increase in the enzyme activity was unaffected. The adenylyl cyclase activities in the absence or presence of cholera toxin were initially increased and then decreased when membranes were treated with a low concentration (0.2 mM) of H2O2 for different time intervals, whereas the enzyme activities in the presence of pertussis toxin were unaltered (Table 4). It should be mentioned that cholera toxin-catalyzed ADP ribosylation and anti-Gs protein binding were seen at both 45- and 52-kDa bands (Fig. 6). Although the cholera toxin-catalyzed ADP ribosylation in the H2O2-treated preparations was depressed at both 45- and 52-kDa bands, Gs protein content (as determined by anti-Gs protein binding) showed an attenuation at the 45-kDa band without any change in the 52-kDa band. No changes in the pertussis toxin-catalyzed ADP ribosylation at 40-kDa and Gi protein content (as measured by anti-Gi protein binding at 40 kDa) were evident due to H2O2 treatment (Fig. 6).
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DISCUSSION |
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Treatment of cardiac membranes with high concentrations of
H2O2
(0.5-5 mM) produced a concentration-dependent depression of the
isoproterenol-stimulated adenylyl cyclase activity. The depressant effect of 1 mM
H2O2
on adenylyl cyclase activity was also evident in the presence of
various concentrations of isoproterenol. Such a depression in the
isoproterenol-stimulated adenylyl cyclase activity may be due to
changes in
-adrenoceptors when cardiac membranes were treated with
H2O2
because a decrease in both the density and affinity
(1/Kd) of
1-adrenoceptors in cardiac
membranes was observed on treatment with 1 mM
H2O2.
Although the density of
2-adrenoceptors in cardiac
membranes treated with
H2O2
was also decreased, the affinity of this subtype of receptors was increased. Such effects of
H2O2
on the density and affinity of
2-adrenoceptors would be of no
major significance because of the opposite changes that would be
elicited in terms of stimulating the adenylyl cyclase activity with
isoproterenol. Because adenylyl cyclase activity in the absence of
isoproterenol was also depressed on treatment of membranes with
H2O2,
it can be argued that the observed decrease in isoproterenol-stimulated
enzyme activity may be related to systems other than changes in
-adrenoceptors. This explanation is supported by the fact that
unaltered or even greater activation of the enzyme by isoproterenol was
seen in all experimental conditions used for the treatment of membranes with
H2O2.
It is possible that changes in
1-adrenoceptors due to
H2O2
may not be of sufficient magnitude for attenuating the response of
adenylyl cyclase to agonist when receptors are occupied with
isoproterenol. Thus the depressed isoproterenol-stimulated adenylyl
cyclase activity does not seem to be dependent on changes in
-adrenoceptors. Nonetheless, the observed changes in the
1- and
2-adrenoceptors should not be
due to any nonspecific action of
H2O2
because Ca2+-channel antagonist
binding in cardiac membranes was not affected by
H2O2
treatment under similar conditions (14).
The evidence presented in this study indicates that alterations in both the catalytic activity of adenylyl cyclase and the function of Gs proteins may contribute to the observed depression in the isoproterenol-stimulated adenylyl cyclase activity in heart membranes on treatment with high concentrations of H2O2. In this regard, adenylyl cyclase activities in the absence (basal) and presence of forskolin, which is known to stimulate the catalytic subunit of the enzyme directly (1), were found to decrease when cardiac membranes were treated with 1 mM H2O2. Furthermore, the depressed adenylyl cyclase activity in H2O2-pretreated membranes, when measured in the presence of Mn2+ without Mg2+, also revealed the effect of H2O2 on the catalytic site of adenylyl cyclase. On the other hand, depression in adenylyl cyclase activities in the presence of both NaF and Gpp(NH)p, which are known to activate the enzyme through their interaction with G proteins (5), indicates changes in G proteins on treatment of cardiac membranes with H2O2. Because the activation of adenylyl cyclase by forskolin, NaF, or Gpp(NH)p in the H2O2-treated membranes was greater than that in the control preparations, it is possible that these responses are determined by changes in the ratio of Gs and Gi proteins on treatment with H2O2. A depression in the Gs protein function by high concentrations of H2O2 is suggested from our observations that adenylyl cyclase activity in the presence of cholera toxin, an activator of Gs proteins (24), was decreased by treatment of cardiac membranes with 1 mM H2O2. In addition, the cholera toxin-catalyzed ADP ribosylation at both 45- and 52-kDa bands of Gs proteins was also depressed by H2O2 treatment. The inability of some investigators (18, 31) to detect changes in cholera toxin-catalyzed ADP ribosylation when vascular smooth cells and cardiac membranes were treated with H2O2 may be due to differences in tissue specificity and experimental design used in these studies. Nonetheless, our results are supported by the fact that the immunoreactivity of the 45-kDa band to antibodies for Gs proteins was markedly depressed when cardiac membranes were treated with H2O2. This action of H2O2 on the anti-Gs protein binding at the 45-kDa band may be selective on this subunit because the decrease in the anti-Gs protein binding at 52-kDa band was not significant. In addition, the depressant effect of H2O2 on cholera toxin-catalyzed ADP ribosylation at the 52-kDa band was less than that seen at the 45-kDa band for Gs proteins in the H2O2-treated membranes. The specificity of the action of H2O2 on Gs protein functions is also evident from the results of this study, indicating no significant changes in adenylyl cyclase activity in the presence of pertussis toxin, an inhibitor of Gi protein (24), as well as in the pertussis toxin-catalyzed ADP ribosylation and binding of antibodies for Gi protein at the 40-kDa band when membranes were treated with H2O2. Thus it appears that a change occurs in the ratio of Gs and Gi proteins on treatment of membranes with H2O2 and that the site of action of H2O2 for reducing Gs protein functions may primarily be at the 45-kDa band of Gs protein.
Although high concentrations of
H2O2
depressed the adenylyl cyclase activities in the absence or presence of
isoproterenol, treatment of membranes with low concentrations of
H2O2
(100 µM) for a period of 10 min was observed to augment the enzyme
activities. An increase in the isoproterenol-stimulated adenylyl
cyclase activity in
H2O2
(100 µM)-treated vascular smooth muscle cells has also been reported
in the literature (31). In fact, an increase followed by a decrease in
adenylyl cyclase activity was seen when cardiac membranes were
pretreated with a low concentration of
H2O2
(200 µM) for different time intervals (5-30 min). A biphasic
pattern of changes in adenylyl cyclase activities in the absence or
presence of cholera toxin was also seen when cardiac membranes were
treated with low concentrations of
H2O2
(200 µM) for different intervals. Such a biphasic effect of
H2O2
on the isoproterenol-stimulated adenylyl cyclase activities appears to
depend on the concentration of
H2O2
as well as time of treatment and may explain the conflicting results
regarding the action of
H2O2
on the
-adrenoceptor-linked mechanisms (7, 13, 18, 31). Because the
density and affinity of
-adrenoceptors were not altered when cardiac
membranes were treated with a 200 µM concentration of
H2O2,
it is unlikely that the increase in isoproterenol-stimulated adenylyl
cyclase activity due to low concentrations of
H2O2
is due to changes in
-adrenoceptors per se. Because the unaltered or
even greater activation of adenylyl cyclase by isoproterenol was seen
during biphasic changes in the adenylyl cyclase activities in the
presence or absence of isoproterenol, it appears that the observed
effects of
H2O2
on
-adrenoceptor mechanisms are of a specific nature and are
consistent with the view that these changes are elicited by the action
of
H2O2
on both catalytic subunit of adenylyl cyclase and
Gs proteins in the membrane.
Although the exact mechanisms by which
H2O2
may alter the
-adrenoceptor, adenylyl cyclase, and G protein system
are unclear, the nature of the modifications of
1-adrenoceptors,
Gs protein functions, and adenylyl
cyclase activity may be suggestive of changes in different protein
components of the
-adrenoceptor complex. This view is supported by
the fact that aldehydes (malondealdehyde and 4-hydroxyneonatal) formed
during lipid peroxidation have been shown to influence the function of
the
-adrenoceptor-adenylyl cyclase system in the sarcolemma by
reacting with NH2 and/or
SH groups of these components (6, 22). The adenylyl cyclase enzyme as
well as
-adrenergic receptors are known to possess SH groups in
their active sites (21, 28), the modification of which may alter the
characteristics of these proteins. It is also possible
that the reduced
1-adrenoceptors,
Gs protein functions, and adenylyl
cyclase activity due to
H2O2
may be caused by the effect of
H2O2-induced
lipid peroxidation (15, 16) on the physical state of the membrane. This
view is based on the fact that the transmembrane
-adrenoceptor
signal transduction has been observed to be depressed by a reduction in
membrane fluidity (25), and lipid peroxidation has been reported to
decrease the membrane fluidity (22). Irrespective of the exact
mechanisms, the results regarding the inhibitory effect of high
concentrations of
H2O2
on the
-adrenoceptor-Gs
protein-adenylyl cyclase pathway may be of some pathophysiological
significance because the concentrations of
H2O2
used in this study are comparable to those reported to occur in the
myocardium during ischemia-reperfusion injury (29, 32).
Although the responses to catecholamines and the
-adrenoceptor mechanisms are attenuated in the ischemia-reperfused hearts (9, 19, 24), the pattern of abnormalities in the
-adrenoceptors, G
proteins, and adenylyl cyclase system may not be exactly similar to
that seen with
H2O2
treatment. Such differences may be attributed to free radicals as well
as active species of oxygen and oxidants other than
H2O2,
which may also be formed in the ischemic-reperfused myocardium (15, 16,
24). Nonetheless, scavenging of
H2O2 by superoxide dismutase plus catalase was found to prevent the ischemia-reperfusion as well as xanthine plus xanthine
oxidase-induced changes in the positive inotropic effect of
isoproterenol and isoproterenol-stimulated adenylyl cyclase activity in
the perfused rat heart preparations (23, 24).
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ACKNOWLEDGEMENTS |
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The research reported in this paper was supported by a grant from the Medical Research Council of Canada (MRC Group in Experimental Cardiology). S. Persad was a predoctoral fellow of the Heart and Stroke Foundation of Canada. H. Rupp was a visiting professor from the Philipps University of Marburg (Marburg, Germany).
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FOOTNOTES |
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Address for reprint requests: N. S. Dhalla, Institute of Cardiovascular Sciences, St. Boniface General Hospital Research Centre, 351 Tache Ave., Winnipeg, Manitoba, Canada R2H 2A6.
Received 8 July 1997; accepted in final form 2 October 1997.
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