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Am J Physiol Heart Circ Physiol 285: H434-H441, 2003; doi:10.1152/ajpheart.00095.2003
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Protein kinase C-{delta} mediates adenosine A3 receptor-induced delayed cardioprotection in mouse

Ting Cun Zhao and Rakesh C. Kukreja

Division of Cardiology, Department of Medicine, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia 23298

Submitted 30 January 2003 ; accepted in final form 14 March 2003


    ABSTRACT
 TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
We investigated the role of protein kinase C in adenosine A3 receptor (A3AR)-induced delayed cardioprotection in the mouse heart. Mice were treated with selective A3AR agonist N6-(3-iodobenzyl)adenosine-5'-N-methyluronamide (IB-MECA). Twenty-four hours later, hearts were perfused in the Langendorff mode and subjected to 30 min of global ischemia and 30 min of reperfusion. Infarct size was determined by computer morphometry of tetrazolium-stained sections, and ventricular function was monitored by inserting a fluid-filled balloon into the left ventricle (LV). Chelerythrine chloride (CHE, 5.0 mg/kg) and rottlerin (Rot, 0.3 mg/kg) were given 30 min before IB-MECA to block total and PKC-{delta} isoforms, respectively. IB-MECA caused postischemic reduction in necrosis and improvement in ventricular function, which was abolished by CHE. Western blot analysis demonstrated translocation of the PKC-{delta} isoform but not the {alpha}, {epsilon}, {xi}, {eta} isoform(s) from cytoplasm to the membrane fraction after 30 min of IB-MECA administration. A3AR antagonist MRS-1191 and CHE blocked the translocation of PKC-{delta}. Furthermore, IB-MECA-induced increase in nuclear factor-{kappa}B binding was diminished by CHE. These results provide direct evidence of an essential role of PKC, and more specifically, PKC-{delta} in A3AR-induced delayed cardioprotection.

adenosine; nuclear factor {kappa}-B; ischemia; reperfusion


ADENOSINE HAS BEEN IDENTIFIED as an important trigger of early (25) and delayed preconditioning in the heart (4, 5), which occurs through activation of one or more adenosine receptor subtypes (1, 2, 46). Four adenosine receptors have been cloned and designated A1,A2a,A2b, and A3 (23, 24). Adenosine A1 and A3 receptors inhibit adenylyl cyclase and stimulate phospholipase C via activation of pertussis toxin-sensitive G proteins Gi and/or Go. Adenosine A2A and A2B receptors are positively coupled to adenylyl cyclase but may also activate alternative signaling pathways (11, 28, 27). The stimulation of adenosine A1 receptor (A1AR) has been implicated in the delayed protection in the rabbit and mouse heart (5, 6, 14, 18, 41). There is increasing evidence that adenosine A3 receptor (A3AR) also exerts early and delayed protective effects in both myocytes (1, 10, 22) and intact hearts (27, 37, 41). We recently (41) demonstrated that stimulation of A3AR with its selective agonist N6-(3-iodobenzyl)adenosine-5'-N-methyluronamide (IB-MECA) induced postischemic improvement in functional recovery and reduction of infarct size. The delayed cardioprotection was attributed to translocation of nuclear transcription factor-{kappa}B (NF-{kappa}B), gene transcription of inducible nitric oxide (NO) synthase (iNOS), synthesis of NO, and opening of the mitochondrial ATP-sensitive K (KATP) channel (42). However, the upstream signaling events involved in A3AR activation of NF-{kappa}B leading to the delayed cardioprotection are not known.

Considerable evidence now supports the involvement of protein kinase C (PKC) in both the early and delayed preconditioning (3, 26). The initial preconditioning stimulus with brief episodes of ischemia induced selective translocation of novel PKC isoforms {epsilon} and {eta} from the cytosolic to the particulate fraction. Chelerythrine, the PKC inhibitor, blocked translocation of the {epsilon}-isoform and abolished delayed preconditioning in the heart (34, 35). In addition to chelerythrine, another PKC inhibitor calphostin blocked the adenosine-induced protective effect in chick embryonic myocytes, although the specific isoform(s) involved was not determined (21). The current study was designed to answer the following questions: 1) whether A3AR stimulation with IB-MECA results in translocation of specific isoform(s) from cytosol to the membrane fractions; 2) whether IB-MECA-induced translocation of PKC isoform(s) as well as delayed cardioprotection is abolished by inhibition of PKC; and finally, 3) to show whether the inhibition of PKC diminishes nuclear translocation of NF-{kappa}B, the transcription factor involved in delayed cardioprotection with A3AR stimulation (30, 42) or ischemic preconditioning (20, 40). The preliminary results of this study were presented at the Scientific Sessions of the American Heart Association (44).


    METHODS
 TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Animals and chemical supplies. Adult male outbred mice (ICR Strain, 30–40 g) were supplied by Harlan (Indianapolis, IN). All animal experiments were conducted under the guidelines on humane use and care of laboratory animals for biomedical research published by National Institutes of Health (No. 85-23, Revised 1996). IB-MECA and MRS-1191 were obtained from Research Biochemicals International (Natick, MA). Chelerythrine and rottlerin were obtained from Sigma Chemical (St. Louis, MO). Gel electrophoresis supplies were obtained from Bio-Rad (Hercules, CA).

Isolated perfused heart and measurement of cardiac function. The methodology of Langendorff-perfused mouse heart preparation, measurement of contractile function, and infarct size were described previously in detail (46). Briefly, a left atrial incision was made to expose the mitral annulas through which a water-filled latex balloon was passed into the left ventricle (LV). The balloon was attached via polyethylene tubing to a Gould pressure transducer that was connected to a Sensormedics polygraph recorder (model RF511A) and a heart performance analyzer (HPA-100, Micro-Med). The balloon was inflated to adjust the LV end-diastolic pressure (LVEDP) to ~10 mmHg. Myocardial ischemic damage was measured using multiple, independent end points of tissue injury. These included infarct size, LV developed pressure (LVDP), LVEDP, rate-pressure product (RPP), heart rate, and coronary flow. LVDP was calculated by subtracting LVEDP from the peak systolic pressure. RPP, an index of cardiac work, was calculated by multiplying LVDP with heart rate.

Experimental protocol A. Mice were randomized to receive various treatments by intraperitoneal injection of drugs or vehicle 24 h before being euthanized and assigned into one of the six groups. Group 1: vehicle (n = 7), treatment with 5% DMSO (0.1 ml); group 2: IB-MECA (n = 8), treatment with selective A3AR agonist IB-MECA (0.1 mg/kg); group 3: chelerythrine + IB-MECA (n = 6), PKC antagonist cherelythrine (5.0 mg/kg) was administered 30 min before IB-MECA; group 4: chelerythrine control (n = 6), pretreatment with chelerythrine alone (5.0 mg/kg); group 5: rottlerin + IB-MECA (n = 6), PKC-{delta} inhibitor rottlerin (0.3 mg/kg) was injected 30 min before IB-MECA; and group 6: rottlerin control (n = 6), mice treated with rottlerin only.

Experimental protocol B. A subset of mice was treated with either DMSO or IB-MECA. At 30, 60, and 240 min post-IB-MECA treatment, LV samples were harvested and stored frozen at -70°C until analyzed for PKC isoforms in the cytosolic and particulate fractions.

Experimental protocol C. The goal of these experiments was to determine whether IB-MECA-induced PKC translocation would be prevented by A3AR antagonist MRS 1191 and chelerythrine. Group 1 and group 2 received 5% DMSO (0.1 ml ip) or IB-MECA (0.1 mg/kg), respectively. Group 3 was the same as group 2 except that MRS 1191 (0.1 mg/kg) was given 30 min before IB-MECA. Group 4 was the same as group 2 except that chelerythrine (5.0 mg/kg) was given 30 min before IB-MECA. Tissue samples were harvested 30 min later for measurement of PKC translocation in the cytosolic and particulate fractions.

Isolation of cytosolic and particulate fractions. The cytosolic and membrane fractions were prepared according to the method of Henry et al. (15). Briefly, frozen tissue samples were ground in liquid nitrogen, lysed, and suspended in buffer A containing (in mmol/l) glycerophosphate 50, EDTA 1, EGTA 20, PMSF 1, leupeptin 0.1, E-64 0.01, CaCl2 0.34, and sucrose 250, along with 0.05% (wt/vol) digitonin. The homogenates were centrifuged at 10,000 g for 2 min, and the supernatant containing the cytosolic proteins was saved. The pellet was resuspended in 200 µl at 4°C in buffer B containing (mmol/l) glycerophosphate 50, EDTA 1, EGTA 20, PMSF 1, leupeptin 0.1, E-64 0.01, along with 1% (vol/vol) Triton X-100. After centrifugation at 10,000 g for 15 min, the supernatant representing the crude membrane fraction was collected. The protein content was determined using the DC-protein assay (Bio-Rad).

PKC Western blot analysis. Cytosolic and membrane fractions were separated by 10% SDS-PAGE. The proteins were transferred on to a nitrocellulose membrane and subsequently blocked with 5% nonfat dry milk in 1x Tris-buffered saline containing 0.5% Tween 20 for 1 h. Antibodies against PKC-{alpha}, -{epsilon}, -{eta}, -{xi}, and -{delta} (Santa Cruze Biotechnology) were used to assess the expression of individual PKC isoforms. The gels were incubated with the respective primary antibodies (1:1,000 dilution) and washed and visualized by incubation with anti-rabbit horseradish peroxidase-conjugated secondary antibody (1:1,000 dilution, Hercules, CA) for 1 h. The PKC immunoblots were developed using ECL chemiluminescence.

Preparation of nuclear extracts. Nuclear extracts were prepared using modification of the method described as previously (45). Briefly, the tissue samples were pulverized in liquid nitrogen and then lysed twice with 1 ml of lysis buffer containing 20 mM Tris (pH 7.9), 140 mM NaCl, 1.5 mM MgCl2, 1 mM EGTA, 1 mM EDTA, 1 mM DTT, 0.5% Nonidet-40 (NP-40), and 0.5 mM of sodium orthovanadate and protease inhibitor (aprotinin, leupeptin, and PMSF). The nuclei were washed once with 1 ml of lysis buffer without NP-40 and resuspended in 150 µl of nuclear extraction buffer (in mM: 50 Tris·HCl, pH 7.9, 60 KCl, 1 EDTA, 1 EGTA, 2 DTT, 1 PMSF, and 0.5 sodium orthavanadate). After three freeze-thaw cycles, the nuclear extracts were obtained by centrifugation at 10,000 g for 15 min.

Electrophoretic mobility shift assay. A double-stranded 22-mer oligonucleotide with the sequence 5'-AGT TGA GGG GAC TTT AGG C-3' (Promega) was end-labeled using [{gamma}-32P]ATP (ICN) and T4 polynucleotide kinase according to the manufacturer's instructions. This oligonucleotide has the consensus sequence for NF-{kappa}B binding, as indicated by underlined sequences. The binding reactions were performed in a final volume of 20 µl containing 10 µg protein, 5% glycerol, 1 µg of poly(dI-dC), and 0.1 ng 32P-labeled NF-{kappa}B oligonucleotide. The reaction mixture was incubated for 30 min at room temperature. The specific protein-DNA complexes were then separated on 5% polyacrylamide gel electrophoresis in 0.5x Tris-borate-EDTA buffer at 40 V. The gel was vacuum dried and exposed to X-ray film at -70°C.

Statistics. All measurements are expressed as means ± SE. The data were analyzed by either unpaired t-test or one-way ANOVA. If a significant value of F was obtained in ANOVA, the Student-Newman-Keuls post hoc test was further used for pair-wise comparisons. A value of P < 0.05 was considered significant.


    RESULTS
 TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Effect of IB-MECA on subcellular distribution of PKC isoforms. As show in Fig. 1, A and B, PKC isoforms {alpha}, {epsilon}, {eta}, {xi}, and {delta} were expressed in both cytosolic and membrane fractions. The expression of these isoforms was generally higher in the cytoplasm compared with the membrane fraction (Fig. 1B). Mice treated with IB-MECA demonstrated no discernible effect on the subcellular distribution of {alpha}, {epsilon}, {eta} and {xi} PKC isoforms compared with the vehicle (5% DMSO). In contrast, PKC-{delta} decreased in the cytosolic fraction with a concomitant increase in the membranous fraction within 30 min after administration of IB-MECA (Fig. 2). Quantitative analysis showed an increase of PKC-{delta} in the particulate fraction from 29.0 ± 7% of the total in the untreated control heart to 51.0 ± 2.2% in IB-MECA-treated hearts after 30 min (P < 0.05). In the cytosolic fraction, the level of this isoform decreased from 70.0 ± 7.0% of the total in controls to 48 ± 1.8% in IB-MECA-treated mice. The translocation was blocked by MRS-1191 as well as chelerythrine. PKC-{delta} in membrane fraction decreased from 51 ± 2.2% of the total in IB-MECA-treated hearts to 17 ± 9.0% in MRS-1191/IB-MECA and 35.0 ± 2.7% of total in chelerythrine-IB-MECA group after 30 min (Fig. 3). Additionally, pretreatment of animals with chelerythrine and MRS-1191 increased the cytosolic PKC-{delta} from 48.0 ± 1.8% of total in IB-MECA-treated hearts to 64.0 ± 2.2% and 83.0 ± 9.0%, respectively.



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Fig. 1. Effect of stimulation of adenosine A3 receptor (A3AR) with N6-(3-iodobenzyl)adenosine-5'-N-methyluronamide (IB-MECA) on subcellular localization of PKC isoforms {alpha}, {epsilon}, {eta}, and {zeta} in the heart. A: Western blot shows subcellular distribution of PKC isoform with stimulation of IB-MECA in cytoplasm and membrane fractions; B: densitometric analysis shows ratio of each fraction with total PKC. Values represent means ± SE (n = 3).

 


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Fig. 2. Time course of activation of PKC-{delta} with stimulation of A3AR. A: Western blot shows subcellular distribution of PKC-{delta} in cytoplasm and membrane fractions; B: densitometric analysis shows ratio of each fraction with total PKC. Values represent means ± SE (n = 3).

 


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Fig. 3. Effect of A3AR antagonist MRS-1191 or PKC inhibitor chelerythrine (CHE) on PKC-{delta} distribution. A: Western blot shows subcellular distribution of PKC-{delta} in cytoplasm and membrane fraction following stimulation with IB-MECA; B: densitometric analysis shows ratio of each fraction with total PKC. Values represent means ± SE (n = 3).

 

NF-{kappa}B DNA binding. NF-{kappa} B binding was low in the control group, which increased rapidly following treatment with IB-MECA (Fig. 4). Both chelerythrine and rottlerin completely blocked IB-MECA-induced NF-{kappa}B binding activity.



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Fig. 4. Effect of CHE on A3AR-induced nuclear factor-{kappa}B (NF-{kappa}B) DNA binding activity. Description of experimental group is provided in Experimental protocol B under METHODS. Nuclear extracts were prepared and incubated with the 32P-labeled NF-{kappa}B oligonucleotide probe to determine the binding activity using electromobility gel shift assay. Figure is representative experiment of three similar gel-shift assays. Rot, rottlerin.

 

Infarct size. Representative sections of the hearts from mice treated with vehicle or IB-MECA are shown in Fig. 5. IB-MECA-treated mice demonstrated a significantly larger area of viable tissue in the postischemic heart (brick red color) compared with the vehicle-treated controls, which had much larger gray and white areas. Quantitatively, the infarct size was 29.9 ± 2.4% in the vehicle-treated hearts, which reduced to 11.3 ± 0.9% after 24 h of treatment with IB-MECA (P < 0.05, Fig. 6). Chelerythrine abolished the protective effect as shown by the increase in the infarct size to 23.7 ± 3.9% (P > 0.05 vs. vehicle). Chelerythrine had no effect on infarct size in the control heart, i.e., 29.8 ± 3. 0% vs. 29.9 ± 2.4% vehicle-treated hearts (P > 0.05). In addition, rottlerin completely blocked the infarct-limiting effect of IB-MECA, i.e., 24.0 ± 3.1% vs. 11.3 ± 0.9% with IB-MECA (P < 0.05), the reduction in infarct size being equivalent to chelerythrine. Rottlerin itself had no effect on infarct size in the control heart (32.0 ± 4.5% vs. 29.9 ± 2.4% in the vehicle group).



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Fig. 5. Representative sections of a heart demonstrating reduction of postischemic infarct size 30 min after treatment with vehicle or IB-MECA. At the end of experimental protocol as described in METHODS, the hearts were sliced into 4–5 sections and stained with 2,3,5-triphenyltetrazolium chloride followed by fixation in formalin. Viable areas are stained brick red, whereas infracted are gray or white. Note that significantly greater viable area in the sections of the heart from IB-MECA-treated mice compared with the DMSO controls.

 


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Fig. 6. Effect of inhibition of PKC on myocardial infarction after ischemia-reperfusion. Description of groups and drug dosages are provided in METHODS. Values represent means ± SE.

 

Ventricular contractile function. As shown in Table 1, the baseline functional parameters, including LVSP, LVEDP, RPP, heart rate, and coronary flow were not significantly different between groups. At the end of reperfusion, RPP (in mmHg/s) was 19.2 ± 2.3 x 103 in the vehicle group, which improved marginally to 28.2 ± 5.6 x 103 with IB-MECA (Fig. 7A). Chelerythrine blocked such improvement in RPP (P ≤ 0.05 vs. IB-MECA-treated hearts), although this inhibitor alone was found to have depressive effect. The reason for the inhibitory effect of chelerythrine on RPP is not clear from this study. Similarly, rottlerin abolished IB-MECA-induced marginal improvement in RPP (8.0 ± 3.5 x103 vs. 28.2 ± 5.6 x 103 with IB-MECA), whereas rottlerin itself had no significant effect in the control group (21.8 ± 7.5 x 103 vs. 19.2 ± 2.3 x 103 in the vehicle group). The postischemic LVEDP (in mmHg) improved in the IB-MECA-treated group (4.5 ± 1.4) compared with the vehicle group (24.5 ± 3.2) (P < 0.05 Fig. 7B). Both chelerythrine and rottlerin abrogated IB-MECA-induced improvement in the recovery of LVEDP (24.8 ± 2.2 and 31.1 ± 3.1 vs. 4.5 ± 1.4 mmHg in IB-MECA group, P < 0.05). In addition, chelerythrine and rottlerin had no effect on LVEDP in the control hearts (28.0 ± 4.9 and 21.9 ± 4.5 mmHg vs. 24.0 ± 3.7 mmHg, P > 0.05). An identical trend in the changes in developed pressure was observed. Postischemic recovery of heart rate and coronary flow was similar in all the groups (not shown).


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Table 1. Baseline functional parameters

 


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Fig. 7. Postischemic recovery of left ventricular rate pressure product (A) and end-diastolic pressure (B) 24 h after IB-MECA treatment. Description of groups and drug dosages are provided in METHODS.

 


    DISCUSSION
 TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The major focus of this investigation was to elucidate the role of PKC and in particular its isoform(s) in delayed cardioprotection induced by selective activation of the A3AR in the mouse heart. Our results show that IB-MECA caused selective translocation of PKC-{delta} from cytosolic to the membrane fraction, which was inhibited by A3AR antagonist MRS-1191 as well as chelerythrine, confirming that stimulation of this receptor subtype is an essential mechanism of translocation. No changes in other PKC isoforms, {alpha}, {epsilon}, {eta}, and {zeta} were observed in the subcellular fractions. The delayed cardioprotection was abolished by rottlerin and chelerythrine with equivalent potency. In addition, chelerythrine inhibited NF-{kappa}B activation, which is known to play an important role in A3AR-induced delayed cardioprotection (42). To our knowledge, this is the first study demonstrating an essential role of PKC-{delta} in cellular signaling that leads to the delayed protective effect of A3AR in the mouse heart.

PKC plays an important role in signal transduction in delayed myocardial preconditioning triggered by stimulation of A1AR against myocardial infarction (18). Ping et al. (35) demonstrated expression and subcellular distribution of 10 PKC isoforms in the rabbit heart. Translocation of PKC isoform(s) from the cytosolic to the particulate fraction (including sarcolemmal, mitochondrial, as well as nuclear fractions) result in their binding to specific receptors of activated C kinase (RACKs) localized in membranes (32). Translocated specific PKC isoforms are believed to participate in several functions, including the opening of mitochondrial KATP channels or the induction of gene expression (35, 39). However, the specific isoform(s) involved in cardioprotection remain controversial. It has been shown that translocation of PKC-{delta}, -{epsilon}, and -{eta} may mediate the cardioprotective effect of ischemic preconditioning in rats and rabbits (16, 35). Also, the PKC-{delta} isoform appears to be more important in pharmacological preconditioning induced by activation of adenosine A1 receptor (18), {delta}1-opioid receptor agonists (12), and {alpha}1-receptor agonist phenylephrine in the rat heart (29). Chen et al. (7) reported opposing effects of PKC-{delta} and PKC-{epsilon} isoforms, i.e., inhibiting PKC-{delta} and activating PKC-{epsilon} reduced damage from simulated ischemia. In the present study, stimulation of A3AR with IB-MECA had no effect on subcellular translocation of PKC-{epsilon}. This discrepancy may be explained by species differences, i.e., mouse versus rabbit or possibly due to different preconditioning stimulus (A3AR stimulation versus ischemic preconditioning). Nevertheless, our results showing translocation of PKC-{delta} coupled with inhibition of the delayed cardioprotective effect with chelerythrine and rottlerin confirm that A3AR mediates a delayed protective effect through the PKC-{delta} isoform. We used rottlerin in this study because it is reported to selectively inhibit PKC-{delta} with an IC50 value of 3–6 µM, and IC50 for the inhibition of PKC-{alpha}, -{beta}, -{gamma}, -{epsilon}, -{eta}, and -{zeta} are in the much higher range, i.e., 80–100 µM (13).

Exactly how A3AR agonist causes activation of PKC-{delta} is not clear from the present study. One possibility is the generation of reactive oxygen species (19), which initiate preconditioning with pharmacological agonists, including acetylcholine, bradykinin, opioids, and phenylephrine (8). In these studies, protection by adenosine or its analog N(6)-(2-phenylisopropyl)adenosine was not be blocked by mercaptopropionylglycine, a putative intracellular antioxidant. However, a preliminary study from our laboratory has shown that the delayed cardioprotective effect of IB-MECA is abolished by prior treatment with the intracellular antioxidant mercaptopropionylglycine (43). Stimulation of A3AR has also been shown to increase intracellular free calcium concentration (18), which may activate the calcium-sensitive PKC-{alpha}. It has been reported that PKC-{alpha} translocated to the cell membrane during ischemic preconditioning and high Ca2+ preconditioning (30, 39). PKC-{delta} is a novel type of PKC that is activated by diacylgycerol but is unresponsive to Ca2+ (17). Lack of translocation of PKC-{alpha}, -{epsilon}, -{zeta}, and -{eta} in the membrane fractions following a bolus dose of IB-MECA in the present studies ruled out the role of these isoforms in A3AR-induced delayed cardioprotection.

The downstream mechanism by which PKC activation confers delayed protection may involve activation of other kinases, including ERK1/2 and p38, which are known to be involved in the ischemic or pharmacological preconditioning (9, 31, 33, 41, 45). It has been shown that A3AR activation with its agonist 5'-N-ethylcarboxamidoadenosine induces phosphorylation and activation of ERK1/2 in Chinese hamster ovary cells expressing the human A3AR (CHO A3 cells) with the same potency (36). Activation of transcription factor NF-{kappa}B by IB-MECA was dependent on PKC because chelerythrine diminished the DNA binding activity in the present studies. Moreover, stimulation of A3AR induced rapid DNA binding of NF-{kappa}B within 30 min, which coincided with translocation of PKC-{delta} in the membrane fraction observed in the present studies. These data appear to be in agreement with the observations that specific inhibition of PKC-{delta} by rottlerin prevented I-{kappa}B{alpha} degradation and NF-{kappa}B activation in TNF{alpha}-stimulated neutrophils (38).

In summary, for the first time, we have demonstrated an essential role of PKC-{delta} in the delayed cardioprotection triggered by stimulation of A3AR in the mouse. The selective early translocation of PKC-{delta} in the membrane fraction may have initiated downstream signaling involving NO generation and opening of the mitochondrial KATP channels, the suspected mediator and effectors of delayed pharmacological preconditioning in the heart.


    ACKNOWLEDGMENTS
 
This work was supported in part by HL-51045 and HL-59469 (to R. C. Kukreja) and Grant-in-Aid 0160420 from Mid-Atlantic Consortium of American Heart Association (to T. C. Zhao).


    FOOTNOTES
 

Address for reprint requests and other correspondence: R. C Kukreja, Cardiology and Emergency Medicine, Division of Cardiology, Box 281, Medical College of Virginia, Virginia Commonwealth Univ., Richmond, VA 23298 (rakesh{at}hsc.vcu.edu).

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.


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