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activation in the mechanism of
preconditioning
Second Department of Internal Medicine, Sapporo Medical University School of Medicine, Sapporo 060-8543, Japan
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ABSTRACT |
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We examined
whether the mitochondrial ATP-sensitive K channel (KATP) is
an effector downstream of protein kinase C-
(PKC-
) in the
mechanism of preconditioning (PC) in isolated rabbit hearts. PC with
two cycles of 5-min ischemia/5-min reperfusion before 30-min
global ischemia reduced infarction from 50.3 ± 6.8% of the left ventricle to 20.3 ± 3.7%. PC significantly increased PKC-
protein in the particulate fraction from 51 ± 4% of the total to 60 ± 4%, whereas no translocation was observed for
PKC-
and PKC-
. In mitochondria separated from the other
particulate fractions, PC increased the PKC-
level by 50%. Infusion
of 5-hydroxydecanoate (5-HD), a mitochondrial KATP blocker,
after PC abolished the cardioprotection of PC, whereas PKC-
translocation by PC was not interfered with 5-HD. Diazoxide, a
mitochondrial KATP opener, infused 10 min before ischemia limited infarct size to 5.2 ± 1.4%, but this
agent neither translocated PKC-
by itself nor accelerated PKC-
translocation after ischemia. Together with the results of
earlier studies showing mitochondrial KATP opening by PKC,
the present results suggest that mitochondrial
KATP-mediated cardioprotection occurs subsequent to PKC-
activation by PC.
mitochondria; protein kinase C; infarct size
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INTRODUCTION |
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THE PHENOMENON of a transient sublethal episode of ischemia affording the myocardium a marked tolerance to subsequent lethal ischemia is termed ischemic preconditioning (PC), and its mechanism has been a subject of intensive investigation over the past decade (6, 20, 21). Involvement of Gi/Gq-coupled receptors as triggers in the PC mechanism has been established (6, 20), and studies to characterize the signal transduction downstream of these receptors have been carried out in a number of laboratories. Furthermore, a substantial amount of evidence indicates that protein kinase C (PKC) activation (15, 17, 19, 24, 40, 42) and opening of mitochondrial ATP-sensitive potassium (KATP) channels (1, 3, 8, 10, 11, 36, 41) are crucial steps in the mechanism of PC. However, the interrelationship between these two has not been fully elucidated. Initially, it was proposed that PKC, which is activated by G protein-coupled receptors, induces opening of the mitochondrial KATP channel, and this hypothesis is supported by two lines of evidence. First, a PKC-activating phorbol ester increased the mitochondrial KATP channel activity, which was monitored by flavoprotein oxidation, in isolated cardiomyocytes (30). Second, we found that infarct size limitation by a selective mitochondrial KATP channel opener (diazoxide) was abolished by a selective inhibitor of the mitochondrial KATP channel (5-hydroxydecanoate, 5-HD) but not by a PKC inhibitor (calphostin C), although both of these inhibitors completely blocked cardioprotection afforded by preischemic activation of a PKC-coupled receptor, adenosine A1 receptor (18).
However, recent studies have suggested that the mitochondrial KATP channel also plays a role in triggering the PC mechanism by producing free radicals (7, 25, 34). Pain et al. (25) reported that transient infusion of a mitochondrial KATP channel opener (diazoxide) mimicked the infarct size-limiting effect of PC, even with a 30-min washout period between the diazoxide infusion and onset of ischemic insult. This effect of diazoxide was abolished by coinfusion of free radical scavengers, suggesting that diazoxide contributes to PC by generation of free radicals. Furthermore, Forbes et al. (7) showed that free radical generation, which was monitored by dichlorofluorescin, was significantly increased by diazoxide in isolated cardiomyocytes. However, whether the mitochondrial KATP channel opening alone is responsible for free radical generation by PC remains unclear. Also, it has not been determined whether opening of the mitochondrial KATP channel is necessary for PKC activation by PC, although pharmacological evidence suggests that the role of free radicals in PC is induction of PKC activation (2).
Accordingly, the present study was aimed to clarify the relationship
between activation of PKC and opening of mitochondrial KATP
channels in the mechanism of cardioprotection by PC in a rabbit model
of myocardial infarction. PKC isoforms that contribute to PC are
species dependent, being the
-isoform in the dog (14),
- and
-isoforms in the rat (12, 17, 38), and the
-isoform in the rabbit (15, 28). Therefore, we
primarily focused on PKC-
and examined 1) whether
both infarct size limitation and translocation of PKC-
afforded by PC are modified by a blockade of the mitochondrial
KATP channel, and 2) whether cardioprotection by
mitochondrial KATP channel opening is accompanied by
translocation of PKC-
in rabbit hearts. Additionally, the effects of
PC and a mitochondrial KATP channel opener on PKC-
and
PKC-
in this species were compared with those on PKC-
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MATERIALS AND METHODS |
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This study was conducted in accordance with The Guide for the Care and Use of Laboratory Animals published by the National Institutes of Health (NIH Publication No. 85-23, Revised 1996) and was permitted by the Animal Use Committee of Sapporo Medical University.
Experiment 1: Studies of Myocardial Infarction
Surgical preparation and perfusion of isolated hearts. Male rabbits (Japanese White), weighing 2.2~2.9 kg, were anesthetized with intravenous pentobarbital sodium (30 mg/kg), tracheostomized, and ventilated with a Harvard respirator (model 683; Harvard Apparatus) using room air and oxygen supplement. After a left thoracotomy, the heart was quickly excised, mounted onto a Langendorff apparatus with a water jacket, and perfused with nonrecirculating modified Krebs-Henseleit buffer (in mM: 118.5 NaCl, 4.7 KCl, 1.2 MgSO4, 1.2 KH2PO4, 24.8 NaHCO3, 2.5 CaCl2, and 10 glucose) at a constant pressure of 75 mmHg. The buffer was gassed with 95% O2-5% CO2, resulting in pH of 7.4-7.5, and the temperature of the perfusate was maintained at 38°C. A fluid-filled latex balloon with a polyethylene-160 tube was inserted into the left ventricle and was connected to an SCK-580 transducer. Baseline left ventricular end-diastolic pressure was adjusted to <5 mmHg. Coronary flow was measured by timed collection of perfusate dripping from the heart. The heart was excluded from the study if the left ventricular systolic pressure was <70 mmHg or if arrhythmias persisted after a 20-min stabilization period.
Experimental protocols. After stabilization, all hearts underwent 30 min of global ischemia and 2 h of reperfusion. Global ischemia was achieved by complete interruption of coronary perfusion. Before global ischemia, each heart was subjected to one of the following six treatments: no pretreatment (control group); two cycles of 5-min global ischemia-5- min reperfusion (PC group); infusion of 100 µM 5-HD, a selective mitochondrial KATP channel blocker, for 5 min before ischemia (5-HD group); a combination of PC and 5-HD infusion (PC + 5-HD group); infusion of 100 µM diazoxide, a selective mitochondrial KATP channel opener, for 10 min before ischemia (diazoxide group); and infusion of 200 nM calphostin C, a PKC blocker, for 15 min and 100 µM diazoxide for 10 min before ischemia (calphostin C + diazoxide group).
We selected 100 µM as the dose of diazoxide for the following two reasons. First, cardioprotection by diazoxide was dose dependent, and 100 µM gave the maximal protection (9). Second, this dose of diazoxide has been demonstrated to indeed open the mitochondrial KATP channel in rabbit cardiomyocytes (30). The dose of calphostin C (i.e., 200 nM) is fourfold higher than its IC50 to inhibit PKC activity, and we confirmed that this dose was sufficient to inhibit PKC translocation by PC in rabbit hearts (unpublished observation). We did not set up a calphostin C control group, because our previous study (18) demonstrated that 200 nM calphostin C alone did not modify infarct size in the same rabbit model of myocardial infarction as that used in the present study.Measurement of infarct size. Infarct size was measured as previously reported (13, 18). In brief, after 2 h of reperfusion, hearts were excised, frozen, and cut into 2-mm-thick sections from apex to base. The uppermost slices, which include valves, were not used for infarct size analysis. Infarcts in the heart slices were visualized by staining with 1% triphenyltetrazolium. The sizes of the infarct and the left ventricle were measured by computer-assisted planimetry. Their volumes were obtained by multiplying each area by 2 mm; i.e., the thickness of the heart slice.
Experiment 2: Western Blotting for PKC
Tissue sampling and sample preparation.
protocol 1
. This protocol was designed to examine translocation of PKC from the
cytosol to the membrane compartments by PC and diazoxide. Rabbit hearts
were isolated and divided into four treatment groups as in
experiment 1: control, PC, PC + 5-HD, and diazoxide
groups. After measurement of basal hemodynamics, left ventricular
biopsy samples (0.5~1.0 g) were taken from the hearts in each study
group at three time points: after stabilization, immediately before the
onset of global ischemia, and at 10 min after ischemia.
Samples at these time points were quickly taken from the apical 1/4,
2/4, and 3/4 of the left ventricle, respectively, using sharp
ophthalmology scissors. Immediately after sampling was performed, the
tissues were frozen in liquid nitrogen and stored at
70°C until
biochemical analysis. Tissue sample preparation was performed as
previously reported (19). In brief, frozen heart samples
were homogenized in cold buffer containing 50 mM Tris · HCl (pH
7.4), 5 mM EDTA, 10 mM EGTA, 50 mM NaF, 50 µg/ml phenylmethylsulfonyl
fluoride, 10 µg/ml leupeptin, and 0.3%
-mercaptoethanol.
The homogenate was centrifuged at 1,000 g for 10 min, and
then the supernatant was centrifuged at 100,000 g for 60 min. The 100,000-g supernatant was designated to the
cytosolic fraction, and the 100,000-g pellet was treated
with 0.3% Triton X-100 and centrifuged at 10,000 g for 10 min to obtain supernatant (particulate fraction). The
1,000-g pellet, which consisted of nuclei and myofibrils,
was not used in the present study. Protein concentration was determined
using a Bio-Rad Protein Assay Kit (Bio-Rad; Hercules, CA).
PKC and cytochrome c Western immunoblotting analysis.
Samples in protocol 1 were electrophoresed on a 12.5%
polyacrylamide gel and then electroblotted onto polyvinylilidine
difluoride membranes (Millipore, Bedford, MA). The blots were
blocked with 5% nonfat dry milk in buffer containing 100 mM NaCl, 10 mM Tris · HCl (pH 7.4), and 0.1% Tween 20 for 1 h. The
blots were then incubated with 1,000-fold diluted antibody against
PKC-
, PKC-
, or PKC-
(Transduction Laboratories; Lexington,
KY). These PKC isoforms were then visualized using an ECL Western
blotting detection kit (Amersham; Buckinghamshire, UK) and
quantified by using SigmaGel, gel analysis software (SPSS; Chicago,
IL). Samples in protocol 2 were electrophoresed on 12.5%
polyacrylamide gel for PKC and also on 15/25% polyacrylamide gel for
cytochrome c detection. Subsequent processes for blotting
and analysis were the same as those for protocol 1 samples.
For cytochrome c detection, 2,000-fold diluted antibody
against cytochrome c (Santa Cruz; Santa Cruz, CA) was used.
Chemicals. Diazoxide, 5-HD, and calphostin C were obtained from Sigma (St. Louis, MO). The other reagents used for preparing heart-perfusing buffer and tissue-homogenizing buffer were purchased from Katayama Chemical (Osaka, Japan).
Statistics. All data are presented as means ± SE. Differences in body weight, heart weight, and infarct size were examined by one-way analysis of variance (ANOVA) combined with the Student-Newman-Keuls post hoc test. Differences in hemodynamics in any given group were compared by two-way repeated-measures ANOVA. An ANOVA with repeated measures was used to analyze the subcellular distribution of PKC isoforms. SigmaStat (SPSS) was used to perform the statistical analysis. The difference was considered significant if the P value was <0.05.
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RESULTS |
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Exclusion of Hearts
Ninety hearts were used in the present experiments. Five were excluded according to the exclusion criteria (i.e., 2 hearts that showed arrhythmias and 3 that failed to develop LV pressure >70 mmHg).Experiment 1
Hemodynamic data.
The hemodynamic parameters are summarized in Table
1. There were no significant differences
in baseline heart rate, left ventricular developed pressure (LVDP), and
coronary flow among the study groups. PC with two cycles of 5-min
global ischemia-5-min reperfusion reduced heart rate and LVDP
and tended to increase coronary flow before the 30-min global
ischemia. Administration of diazoxide had little effect on
heart rate and LVDP but significantly increased coronary flow. LVDP and
coronary flow after reperfusion were significantly decreased in all
groups, but recovery of LVDP was better in the diazoxide-treated hearts
than that in the controls.
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Infarct size data.
As shown in Table 2, body weight, heart
weight, and left ventricular volume were comparable among the study
groups. Infarct size as a percentage of the left ventricle (%IS/LV) in
each heart is presented in Fig. 1. PC
significantly reduced %IS/LV from 50.3 ± 6.8% of the control
value to 20.3 ± 3.7%. This infarct size-limiting effect of PC
was completely blocked by 5-HD, although 5-HD alone did not modify
%IS/LV. Diazoxide significantly reduced %IS/LV to 5.2 ± 1.4%.
This cardioprotective effect of diazoxide was not inhibited by
pretreatment of hearts with calphostin C (%IS/LV = 7.0 ± 1.7%).
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Experiment 2
Protocol 1.
There were no significant differences in heart rate, LVDP, and
coronary flow among the groups before left ventricular biopsies were
performed (data not shown). The percentage of particulate fraction in
total (i.e., particulate fraction/cytosolic fraction plus particulate
fraction; %PF) of PKC-
under the baseline condition was 53 ± 3%, and it was increased to 66 ± 2% after 10 min of
ischemia (P < 0.05; Fig.
2A). Because there was no
significant change in %PF after the time control period in the control
group (base vs. treatment in Fig. 2A), it is unlikely that
our sampling method alone substantially affected PKC distribution. PC
significantly increased the %PF of PKC-
from 51 ± 4% at
baseline to 60 ± 4%, and it was further increased to 71 ± 3% after 10 min of ischemia (both P < 0.05 vs. baseline; Fig. 2B). Infusion of 5-HD did not inhibit the
increase in %PF of PKC-
after PC and after 10 min of
ischemia (55 ± 4% and 69 ± 2%, respectively, both
P < 0.05 vs. 45 ± 6% at baseline; Fig.
2C). Diazoxide neither increased the %PF of PKC-
by
itself nor accelerated the increase in the %PF of PKC-
after
ischemia (Fig. 2D). In contrast to the alteration of
PKC-
, the %PF of PKC-
and %PF of PKC-
were not increased either by PC, diazoxide, or ischemia (Fig.
3, A-D).
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Protocol 2.
Cytochrome c was detected almost exclusively in the
mitochondrial fractions, confirming proper separation of the
mitochondria. Under the baseline condition, PKC-
level in the
mitochondria fraction (per gram protein) was 3% of the total. This
level was 52% and 45% in the cytosolic and SR/SL fractions,
respectively. Accordingly, to clearly present changes in the
mitochondrial PKC-
, the levels of mitochondrial PKC-
after PC and
drug treatments were presented as percentages of the baseline value
(Fig. 4). PC increased the mitochondrial
PKC-
level by ~50% and tended to further increase the level after
10 min into the index ischemia. This time course of PKC-
level in the mitochondria after PC and subsequent ischemia was
not modified by administration of 5-HD. Diazoxide did not modify the
mitochondrial PKC-
level before and after 10 min ischemia.
Alterations in PKC-
level in the SL/SR fraction after PC and drug
treatment were essentially the same as those in the particulate
fractions in protocol 1 (data not shown).
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DISCUSSION |
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The present study showed that 5-HD administered after PC
ischemia completely inhibited infarct size limitation by PC
without having any effect on PKC-
translocation from the cytosol to
the membrane fractions, including mitochondria. Furthermore, direct opening of the mitochondrial KATP channel by diazoxide
limited infarct size, whereas this mitochondrial KATP
channel opener neither translocated PKC-
by itself nor accelerated
PKC-
translocation after ischemia. The cardioprotection
afforded by diazoxide was not abolished by a PKC inhibitor, calphostin C.
These results indicate that translocation of PKC-
is not sufficient
but that activation of the mitochondrial KATP channel before ischemia is necessary for cardioprotection afforded by PC. Together with earlier findings regarding PKC-induced mitochondrial KATP channel opening (30), the present
findings suggest that activation of the mitochondrial KATP
channel occurs downstream from the PKC-
translocation in the
mechanism of PC against infarction.
Brief ischemia simultaneously activates several PKC isoforms,
and different PKC isoforms have been suggested to be responsible for PC
effects in various animal species (14, 17, 26-28,
31). However, two lines of evidence strongly support the notion
that PKC-
is the isoform relevant to PC in rabbit cardiomyocytes
(15, 28). In this species, only
- and
-isoforms of
PKC are activated by repetitive brief ischemia, and tolerance
of the cardiomyocytes to ischemic injury was found to be
correlated with translocation of PKC-
but not with that of PKC-
(28). Furthermore, a peptide selectively antagonizing
PKC-
receptor protein inhibited PC in isolated rabbit
cardiomyocytes, whereas such an effect on PC was not detected for
peptides that antagonize receptor proteins for other PKC isoforms
(15). In the present experiments, the particulate fraction
of PKC-
was significantly increased after two cycles of 5 min of
ischemia and 5 min of reperfusion and further translocation of
PKC-
was observed after 10 min of subsequent ischemia (Fig. 2B). This cumulative response to repetitive ischemia
was similar to that in a study by Ping et al. (28), in
which translocation of PKC-
exhibited a dose-dependent pattern in
response to the number of ischemia-reperfusion cycles. In
contrast, neither PKC-
nor PKC-
translocated either after PC or
after 10 min of sustained ischemia (Fig. 3). These findings are
consistent with earlier observations (28) and confirm that
a pattern of PC-induced translocation of PKC isoforms in rabbit hearts
differs from the pattern in rat hearts, in which both PKC-
and
PKC-
translocates to the membrane fractions after PC (12,
17).
To examine whether PKC-
directly translocates to the mitochondria
after PC, we assessed the PKC level in the mitochondrial fraction in
protocol 2. Consistent with the results of a recent preliminary study in the mouse (4), PKC-
was detected
in the cardiac mitochondria from the rabbits, although its level was substantially lower than those in the cytosol and the other membranes. PKC-
in the mitochondrial fraction was significantly increased after
PC, and the effects of 5-HD and diazoxide on the mitochondrial PKC-
(Fig. 4) were also similar to those on PKC-
in the SL/SR fraction
(data not shown) and in the nonseparated particulate fractions (Fig.
2). Therefore, these results do not allow us to specify the site of
PKC-
translocation, which is crucial for transduction of PC-related
signals. However, the findings in PKC-
in the mitochondria (Fig. 4)
and in the total membrane fractions (Fig. 2) indicate that both the
inhibitory effect of 5-HD on PC protection and the diazoxide-induced
cardioprotection (Fig. 1) are independent of translocation PKC-
to the mitochondria and other membrane compartments.
There is pharmacological evidence indicating that PKC induces
activation of the mitochondrial KATP channel
(30). However, it is still not clear how PKC-
translocation induces opening of the mitochondrial KATP
channel. It is possible that PKC-
translocated to the mitochondria
directly regulates the mitochondrial KATP channel activity.
However, we cannot exclude the possibility that PKC-
translocated to
the sarcolemma induces a cascade of protein kinase activation, which
also contributes to facilitated opening of the mitochondrial
KATP channel. Mitogen-activated protein kinases (MAPKs)
(26, 29) and Src and Lck tyrosine kinases
(27) are suggested to be kinases subsequently activated
by PKC-
. Interestingly, a p38-MAPK blocker, SB-203580,
abrogated PC-induced infarct size limitation (16, 23, 29).
Furthermore, anisomycin, which is an activator of p38-MAPK, mimicked PC
effects on infarct size (3, 22), and this protective
effect was completely inhibited by 5-HD in a study by Baines et al.
(3). Therefore, p38-MAPK might be responsible for
transmission of signals from PKC-
to the mitochondrial
KATP channel.
The results of the present study strongly support the notion that the
mitochondrial KATP channel is an effector downstream of PKC
in the mechanism of PC in the rabbit heart. However, a series of
studies by Wang et al. (37-39) suggests that PKC
activity is important for mitochondrial KATP channel
opening to enhance anti-ischemic tolerance in rat hearts. In
their studies (37-39), PKC inhibitors and PKC
downregulation prevented both PKC-
translocation and
cardioprotection that were induced by diazoxide pretreatment in
isolated rat hearts. In contrast, in rabbit hearts, neither PKC-
nor
PKC-
was translocated after diazoxide infusion (Figs. 2 and 3), and
PKC inhibitors (calphostin C and chelerythrime) failed to abolish the
infarct size-limiting effect of diazoxide (18, 25) (Fig.
1). These discrepancies cannot be readily explained but may be due to
species differences in the PC mechanism. In fact, species
differences in the PC mechanism have been suggested with respect to the
roles of adenosine receptors (6), PKC isoforms (12, 14, 17, 28), and the relationship between PKC and tyrosine kinase (33, 35, 42).
In the present study, we cannot totally exclude the possibility that
the mitochondrial KATP channel activity during repetitive PC contributed to translocation of PKC-
. Because 5-HD was infused from the end of the second PC ischemia to the onset of
sustained ischemia, activity of the mitochondrial
KATP channel was undisturbed during the first PC
ischemia-reperfusion and the second PC ischemia. However, it is unlikely that the mitochondrial KATP channel
activity during that period of the PC protocol played a major role in
induction of PKC-
translocation. First, a single cycle of PC did not
afford significant infarct size limitation in the present model of
infarction (unpublished observation). Second, translocation of PKC-
was not provoked by a relatively high dose of diazoxide (Figs.
2D and 4), although the same dose of diazoxide afforded
larger cardioprotection than that afforded by PC (Fig. 1). In the
present study, cardioprotection was greater in diazoxide-treated
hearts than in the preconditioned hearts (i.e., infarct size limitation
by 90% vs. 60%), as was found in our recent study using the same
isolated rabbit heart preparation (32). This difference
may be explained by the possible difference in the extents of the
mitochondrial KATP channel opening, because
diazoxide-induced protection is dose dependent (9) and is completely abolished by 5-HD (3, 18, 32) as is
cardioprotection afforded by PC (1, 6, 8).
Although PC increased PKC-
in the membrane compartments before the
onset of ischemia, the PKC-
levels 10 min after the onset of
ischemia in nonpreconditioned and preconditioned hearts were comparable (Fig. 2, A vs. B). These findings
indicate the importance of the PKC-
level at the time of
ischemia onset and do not necessarily argue against our
proposal that PKC-
opens the mitochondrial KATP channels
in PC. Studies on the critical timing of PKC activation and
mitochondrial KATP channel opening for cardioprotection
suggest that their interaction in PC may be during the very early phase of index ischemia. Yang et al. (40) demonstrated
that PKC activity during the first 10 min of index ischemia is
crucial for PC to be protective. Our recent study (34)
using diazoxide showed that the mitochondrial KATP channel
needs to be activated during the early phase of sustained
ischemia to protect the cardiomyocytes from ischemic
necrosis. Taken together, the results suggest that the level of PKC-
translocation at the onset of ischemia is important in the PC
mechanism because it enables enhanced and earlier opening of the
mitochondrial KATP channels during ischemic insult.
In the present experiments, as in earlier studies (1, 8),
5-HD infused after PC eliminated anti-infarct tolerance in the
preconditioned heart, indicating the importance of mitochondrial KATP channel activity during ischemia in PC-induced
protection. However, in a recent study by Pain et al.
(25), 5-HD administered after PC did not abolish the PC
effect on infarct size. We do not have a clear explanation for this
contradiction, but there are two possible reasons. First, the levels of
mitochondrial KATP channel activation by PC may be
different in these experiments, resulting in different responses to
similar doses of 5-HD. Second, in addition to the mitochondrial
KATP channel, there may be an effector of PC [such as
cytoskeletal proteins (3)], and its contribution may have
been predominant, masking the role of the mitochondrial
KATP channel under the experimental conditions employed by
Pain et al. (25). Nevertheless, the present findings (Fig. 2) suggest that anti-infarct tolerance afforded by mitochondrial KATP channel activation does not depend on PKC-
translocation before and after ischemic insult in cardiomyocytes.
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ACKNOWLEDGEMENTS |
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This study was supported in part by a grant-in-aid for Scientific Research 13670731 (to T. Miura) from the Ministry of Education, Culture, Sports, Science and Technology, Japan.
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FOOTNOTES |
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Address for reprint requests and other correspondence: Tetsuji Miura, Second Dept. of Internal Medicine, Sapporo Medical Univ. School of Medicine, South-1, West-16, Chuo-ku, Sapporo 060-8543, Japan (E-mail: miura{at}sapmed.ac.jp).
The costs of publication of this article were defrayed in part by the payment of page charges. The article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
First published March 28, 2002;10.1152/ajpheart.00434.2001
Received 22 May 2001; accepted in final form 26 March 2002.
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