Conceived and designed the experiments: EN ET GKH LS JZH AG. Performed the experiments: EN MDS LF LC JK AW LS AG. Analyzed the data: EN MDS LF LC JK AW ET GKH LS JZH AG. Contributed reagents/materials/analysis tools: JK ET GKH LS JZH AG. Wrote the paper: EN MDS LF LC JK AW ET GKH LS JZH AG.
The authors have declared that no competing interests exist.
Cysteinyl-leukotrienes (cys-LT) are powerful spasmogenic and immune modulating lipid mediators involved in inflammatory diseases, in particular asthma. Here, we investigated whether cys-LT signaling, in the context of atherosclerotic heart disease, compromises the myocardial microcirculation and its response to hypoxic stress. To this end, we examined Apoe−/− mice fed a hypercholesterolemic diet and analysed the expression of key enzymes of the cys-LT pathway and their receptors (CysLT1/CysLT2) in normal and hypoxic myocardium as well as the potential contribution of cys-LT signaling to the acute myocardial response to hypoxia.
Myocardial biopsies from Apoe−/− mice demonstrated signs of chronic inflammation with fibrosis, increased apoptosis and expression of IL-6, as compared to biopsies from C57BL/6J control mice. In addition, we found increased leukotriene C4 synthase (LTC4S) and CysLT1 expression in the myocardium of Apoe−/− mice. Acute bouts of hypoxia further induced LTC4S expression, increased LTC4S enzyme activity and CysLT1 expression, and were associated with increased extension of hypoxic areas within the myocardium. Inhibition of cys-LT signaling by treatment with montelukast, a selective CysLT1 receptor antagonist, during acute bouts of hypoxic stress reduced myocardial hypoxic areas in Apoe−/− mice to levels equal to those observed under normoxic conditions. In human heart biopsies from 14 patients with chronic coronary artery disease mRNA expression levels of LTC4S and CysLT1 were increased in chronic ischemic compared to non-ischemic myocardium, constituting a molecular basis for increased cys-LT signaling.
Our results suggest that CysLT1 antagonists may have protective effects on the hypoxic heart, and improve the oxygen supply to areas of myocardial ischemia, for instance during episodes of sleep apnea.
Chronic ischemic heart disease is characterized by inadequate oxygen supply to the myocardium at rest or in response to increased demand and is usually caused by flow restriction with normal blood oxygen content. However, under certain circumstances reduction in oxygen supply due to decreased blood oxygen content may be the main eliciting cause of inadequate oxygen supply to the myocardium, as for example observed during sleep apnea.
Patients with sleep apnea exhibit a variant number of reductions and severity of decreased blood oxygen content during sleep. Notably, systemic leukotrienes are increased in patients with obstructive sleep apnea and increased LTB4 signaling has been suggested to contribute to development of atherosclerotic lesions
It is therefore possible that during bouts of hypoxia, such as those seen with sleep apnea disorders, the heart begins to produce leukotrienes
Such a notion would require that 1) the constitutional components of the cys-LT pathway are expressed in the myocardium and 2) that interruption of cys-LT signaling during bouts of hypoxia is beneficial. Accordingly, we investigated the gene expression and role of the cys-LT signaling cascade in a mouse model of atherosclerotic heart disease and compared the results with gene expression data from specimens of human myocardium. Specifically, we tested the hypothesis that cys-LT signaling plays a role in sustaining myocardial ischemia during bouts of hypoxia in chronic ischemic heart disease.
It is well known that Apoe−/− mice develop hypercholesterolemia and atherosclerotic lesions, including the coronaries
Heart weight/animal weight ratios are significantly increased in Apoe−/− mice compared to C57BL/6J (**, p<0,01 versus C57BL/6J) (Panel A). Hypercholesterolemic diet led to a strong increase of interstitial matrix collagen deposition in Apoe−/− compared to C57BL/6J under both normoxic and hypoxic condition (Panel B left). We analyzed 3 coronal area sections from each animal and the results are expressed using a semiquantitative score: 1 absent collagen, 2 mild collagen deposition, 3 severe collagen deposition. Panel B right is a representative image of absent (1), mild (2) and severe (3) collagen deposition. The number of apoptotic cells is significantly increased in Apoe−/− compared to C57BL/6J only under normoxic condition. We performed TUNEL staining on 3 coronal area sections from each animal and results are expressed as mean of number of apoptotic cells (*, p<0.05 versus C57BL/6J normoxia) (Panel C left). Panel C right is a representative image of positive TUNEL staining (1, arrow) and overlap with propidium iodide as a nuclei marker (2, arrow). Results presented are mean±SD of C57BL/6J normoxia n = 4; C57BL/6J hypoxia n = 5; Apoe−/− normoxia n = 6; Apoe−/− hypoxia n = 7.
In addition, we analyzed if increased cell apoptosis correlated with atherosclerotic heart disease, applying a TUNEL staining procedure. TUNEL positive cells were considerably increased in Apoe−/− compared to C57Bl6 mice (
Moreover, we found that the expression of IL-6 was robustly increased in Apoe−/− mouse hearts as compared to wild type mice (p<0.05) whereas the expression levels of TNFα, CCL-2, ICAM-1, and MIB-2 were not significantly altered (
In the Apoe−/− mouse model, baseline heart levels of IL-6 are increased as compared to control C57BL/6J mice whereas levels of TNF-a, Ccl2, ICAM-1, MIB-2 are unaltered. Each experiment was run in duplicate and changes in mRNA levels were expressed as ΔΔCt values and presented as relative to the mean of C57BL/6J mice. Values are mean±SD of C57BL/6J n = 4; Apoe−/− n = 6. *, p<0.05.
We assessed the profile of LT cascade proteins at the mRNA level. In the Apoe−/− heart, mRNA levels of LTC4S and CysLT1 were significantly upregulated as compared to control C57BL/6J mice whereas 5-LO levels remained unaltered (
In the Apoe−/− heart, levels of LTC4S and CysLT1 are significantly upregulated as compared to control C57BL/6J mice (Panel A). Acute hypoxic stress in Apoe−/− mice increases the cardiac expression of LTC4S (p<0.05) and CysLT1 (p = 0.06 for two sided t-test, p<0.05 for one sided t-test) compared to normoxic conditions (Panel B). Each experiment was run in duplicate and changes in mRNA levels were expressed as ΔΔCt values and presented as relative to the mean of C57BL/6J mice (Panel A) or normoxia (Panel B). Values are mean±SD of C57BL/6J normoxia n = 4; Apoe−/− normoxia n = 6; Apoe−/− hypoxia n = 7. *, p<0.05; **, p<0.01.
Immunohistochemistry analysis confirms CysLT1 receptor expression in mouse heart tissue notably in endothelial cells. The panels show representative immunostaining for CysLT1 receptor expression in (A) Apoe−/− without hypoxia; (B) Apoe−/− following hypoxic stress and (C) negative controls. The arrows point to positive staining cells. The results are representative of staining performed in n = 6 per group.
Additional experiments were performed to determine the effects of acute hypoxic stress on LT pathway gene expression in Apoe−/− mice. At 48 h after a bout of hypoxia a further increase in the expression of LTC4S (p<0.05) and CysLT1 (p<0.05) (
To detect LTC4S enzyme activity, microsomal preparations were isolated from Apoe−/− heart tissue and incubated with intact LTA4, the key unstable intermediate of the LT cascade. Coupled HPLC/EIA analysis detected significant formation of LTC4, which increased in heart tissue from Apoe−/− mice, particularly following hypoxic stress (
LTC4S enzymatic activity is enhanced in Apoe−/− mice compared to C57BL/6J mice under both normoxic (not statistically significant) and hypoxic conditions (#, p<0.05 versus C57BL/6J hypoxia). LTC4S enzymatic activity was enhanced by 10-fold in Apoe−/− mice under acute hypoxia compared to normoxia condition (*, p<0.05 versus Apoe−/− normoxia). Results expressed as LTC4 (pg/mg microsomal pellet) are mean ± SD of C57BL/6J normoxia n = 3; C57BL/6J hypoxia n = 5; Apoe−/− normoxia n = 4; Apoe−/− hypoxia n = 3.
To evaluate the hypoxic load, mouse heart samples were stained with hypoxyprobe. Hypoxic myocardial load, expressed as % positive staining area, was significantly enhanced upon acute hypoxic stress in Apoe−/− mice. In contrast, no changes were observed in the hypoxic myocardial area when C57Bl6 mice were subjected to acute hypoxia. When Apoe−/− mice were pretreated with montelukast and subjected to an acute hypoxic stress, the hypoxic myocardial load decreased to basal normoxic levels (
Hypoxic myocardial load is significantly upregulated under acute hypoxic stress in Apoe−/− (#, p<0.05 versus Apoe−/− normoxia); pretreatment with Montelukast (Hypoxia+MTK) reduces hypoxic myocardial load to levels equal to those observed in hearts of Apoe−/− mice under normoxia (**, p<0.01 versus Apoe−/− hypoxia) (Panel A). Panel B is a representative immunostaining for negative control (1) and positive staining (2) with 2 different magnifications. Hypoxyprobe signal was detected and quantified as described in the methods section. Results of Panel A are expressed as mean±SD of C57BL/6J normoxia n = 4; C57BL/6J hypoxia n = 5; Apoe−/− normoxia n = 6; Apoe−/− hypoxia n = 7; Apoe−/− hypoxia with montelukast pre-treatment n = 7.
We performed mRNA expression analyses of 5-LO, LTC4S and the CysLT1 receptor on a unique collection of human heart biopsies, obtained from chronic ischemic and non-ischemic parts of the same heart; i.e. each heart biopsy in chronic ischemic area was compared with a control biopsy from the same patient in a non-ischemic area. A significant increase in both LTC4S and CysLT1 mRNA levels was observed in chronic ischemic human myocardium (compared to non-ischemic myocardium) (
In chronic ischemic myocardium, levels of LTC4S and CysLT1 are significantly upregulated as compared to non-ischemic myocardium. In each patient a heart biopsy from chronic ischemic area was compared with a control biopsy from the same patient in a non-ischemic area. Each experiment was run in duplicate and changes in mRNA levels were expressed as ΔΔCt values and presented as relative to the mean of non-ischemic myocardium. Values are mean ± SD of n = 14 patients. **, p<0.01.
Leukotrienes are potent pro-inflammatory lipid mediators and over the past years several studies have implicated LTs, in particular LTB4, in the inflammatory component underlying vascular inflammation, atherosclerosis, and atherothrombosis
In the present study we chose the Apoe−/− mouse as a model of atherosclerotic heart disease and assessed the gene expression profile of the LT cascade. The Apoe−/− mouse develops hypercholesterolemia and extensive atherosclerotic lesions throughout the arterial tree as well as coronary atherosclerosis
Previous clinical investigations have demonstrated increased levels of urinary LTE4, a stable and bioactive metabolite of LTC4, in patients with sleep apnea
Furthermore, it is not previously known whether an acute hypoxic stimulus increases the expression of genes involved in LT production and signaling, which in turn would point to a possible link between hypoxia and inflammation in the heart. It was therefore of interest to assess the effects of a bout of hypoxic stress on LT-pathway gene expression. In our model, there was a pronounced increase in the expression of LTC4S and CysLT1 in response to hypoxic stress. In addition, we could detect a tendency towards increased expression of 5-LO, the upstream enzyme in LT biosynthesis. One could argue that increased expression of cys-LT system components are due to an increased influx of inflammatory cells in chronic hypoxic myocardium or following hypoxic stress. Although a contribution from recruited leukocytes cannot be entirely excluded it does not appear a likely explanation to our data, because we had no evidence of myocardial infarction by histology or troponin measurements and we counted inflammatory cells and found no differences in numbers of CD68+ cells.
CysLT1 protein was localized by immunohistochemistry to vascular (possibly endothelial) cells in heart tissue of Apoe−/− mice. In the absence of a specific antiserum for LTC4S, we used a biochemical approach to demonstrate the presence of active enzyme in the mouse myocardium. Thus, incubation of heart membrane preparations with intact LTA4, followed by analysis with HPLC coupled to EIA, revealed significant formation of LTC4, which increased in heart tissue from Apoe−/− mice, particularly following hypoxic stress. Because there is only one membrane enzyme with significant ability to conjugate LTA4 with GSH to form LTC4,
To test whether pharmacological interruption of the cys-LT signaling pathway could have an impact on the hypoxic load of the myocardium, Apoe−/− mice were subjected to hypoxia in the presence or absence of montelukast, a selective antagonist of CysLT1. Administration of this drug reduced the hypoxic load of the myocardium to levels equal to those observed in hearts of Apoe−/− mice under normoxic conditions. Since expression of LTC4S was also increased in the heart of Apoe−/− mice, an alternative pharmacological approach to block cys-LT signaling could be inhibition of LTC4S
In studies of the pathological role of LTs, animal disease models have been of variable value. For instance, few, if any, mouse models reproduce human LT-driven asthma and for atherosclerosis, the Apoe−/− model has provided ambiguous results
In conclusion, we have demonstrated that LTC4S and CysLT1 receptor gene expression is up-regulated in the heart and can be further enhanced by bouts of hypoxic stress in a mouse model of atherosclerotic heart disease. Blocking cys-LT signaling by montelukast abolishes the aggravated hypoxic load in response to hypoxia indicating that cys-LTs compromise oxygen supply, presumably via actions on the myocardial microcirculation. We also demonstrate a highly similar gene-expression pattern in the chronic ischemic human heart suggesting that similar mechanisms are operating in humans. These findings link myocardial hypoxia to inflammatory cys-LT signaling, vasoconstriction and acute hypoxic events, and prompts for testing of anti-leukotriene drugs in humans at risk for decreased blood oxygen content (e.g. sleep apnea) and with obstructive coronary artery disease.
Animal procedures were approved by the Stockholm Ethical Committee on Animal Experiments (D.Nr. N28/07/N360/07). Male Apo-lipoprotein E-deficient [Apoe−/−] and C57BL/6J mice were fed a Western-type diet for 1 year. Apoe−/− mice were treated with either vehicle i.p. dimethyl sulfoxide (DMSO) (n = 7, group A), montelukast 10 mg/kg i.p. (MTK) dissolved in DMSO (n = 7, group B) or left untreated (n = 6, group C). C57BL/6J mice were treated with vehicle i.p. (DMSO) (n = 5, group D) or left untreated (n = 4, group E). One hour after treatment, groups A, B, and D were exposed to hypoxic stress (10% O2) for 30 min. DMSO and montelukast treatment were repeated 24 h after hypoxic stress and animals were euthanized at 48 h. 30 min before euthanasia mice received pimonidazole hydrochloride (60 mg/kg i.p.; Hypoxyprobe, Chemicon International, Inc., Temecula, CA). Following perfusion with PBS, the hearts were collected and divided into thin slices and either embedded in OCT and flash-frozen or preserved in formaldehyde and paraffin-embedded. Cardiac troponin-I plasma levels were determined by ELISA (Life Diagnostics Inc., West Cheater, PA).
Myocardial sections were stained with hematoxylin eosin. Heart slices were also incubated with either Hypoxyprobe 1 Mab1 bound to FITC (diluted 1∶100, Chemicon International) for 1 h at room temperature or with CysLT1 receptor rabbit polyclonal antibody (diluted 1∶50, Cayman) overnight at 4°C. Hypoxyprobe signal was developed using anti-FITC/HRP complex (diluted 1∶200, Chemicon International), ABC-PO complex (Vectastain ABC Kit, PK-6100 standard, Immunokemi), and DAB substrate (Peroxidase substrate kit, SK-4100, Vector Laboratories) and counterstained with Mayer’s hematoxylin. Hypoxic area was quantified using Leica QWin Image analysis software (Leica, Wetzlar, Germany). CysLT1 receptor signal was developed with anti-rabbit biotinylated antibody (diluted 1∶500, PerkinElmer), streptavidin-HRP conjugated (diluted 1∶100, PerkinElmer), DAB substrate (Peroxidase substrate kit, SK-4100, Vector Laboratories) and counterstained with Mayer’s hematoxylin. Picrosirius red staining was performed on paraffin-embedded heart tissue sections for 1 hour in saturated picric acid containing 0.1% picrosirius red (Direct Red 80; Fluka, Buchs, Switzerland).
The ApoAlert DNA Fragmentation Assay Kit (Clontech) was used to detect apoptosis-induced nuclear DNA fragmentation using a fluorescence assay according to the instructions by the manufacturer, and expressed as number of apoptotic cells per total area. Mouse thymus was used as TUNEL staining positive control.
Heart microsomal fractions in aliquots of 85 µL, supplied with GSH (5 mM) and BSA (10 µg/µL), were incubated at RT for 10 min with LTA4 lithium salt (1 µM). Reactions were stopped with 2 vol. methanol containing 125 pmol of PGB2 as the internal standard, acidified to pH 5.6 [citrate (0.1 M)-Phosphate (0.2 M) buffer], and precipitated proteins removed by centrifugation (1000 x g, 4°C, 5 min). LTA4 transformation products were extracted on a Sep-Pak C18 cartridge (Oasis, Waters), samples eluted in 1 mL of methanol, dried under a N2 stream, reconstituted in methanol/water (1∶1) and analyzed by RP-HPLC coupled to enzyme-immunoassay (EIA kit, Cayman Chemical). Control LTA4 incubations with buffer alone or with recombinant LTC4S were run in parallel.
All subjects gave informed consent and the investigation was approved by the ethical committee of Copenhagen (KF 01–225/01) and the Karolinska Hospital (03–360). A total of 14 patients (
Patients | |
Age (years, mean ± SE) | 68±2 |
Sex (M/F) | 12/2 |
Diabetes, |
3 |
LVEF (%, mean ± SE) | 55±3 |
Hyperlipidemia, |
11 |
Previous STEMI, |
6 |
Prior PCI, |
2 |
Prior CABG, |
0 |
CCS class (mean ± SE) | 2.4±0.1 |
NTG, |
8 |
β-blocker, |
10 |
Ca2+ antagonist, |
5 |
Statin, |
12 |
Duration of acute myocardial ischemia (minutes, mean [min–max]) | 54 (28–100) |
Time from reperfusion to biopsy (minutes, mean [min–max]) | 36 (20–75) |
Coronary artery stenosis | |
70–90% | 14 |
90–95% | 22 |
>95% | 64 |
2-vessel disease (stenosis >70%), |
5 |
3-vessel disease (stenosis >70%), |
9 |
Values are expressed as number (
RNA from left ventricular mouse heart tissue and human left ventricular heart biopsies was isolated with RNeasy mini kit (Qiagen) according to the manufacturer’s instructions. Quantity and quality was controlled using an Agilent Bioanalyzer 2100 (Agilent Technologies, Palo Alto, CA, USA). Complementary DNA (cDNA) was reverse transcribed from 0.5–1 µg of total RNA using random hexamer primers. Quantitative real-time PCR was performed on an ABI Prism 7700 sequence detector (Applied Biosystems, Foster City, CA, USA) with primer and probes purchased from assay-on-demand (Applied Biosystems). Changes in mRNA levels were expressed as ΔΔCt using Cyclophilin A as endogenous control
Two sided parametric t-test, two-way ANOVA with a post hoc Holm-Sidak test was used to detect statistically significant differences (p<0.05) unless otherwise indicated. Data are expressed as mean ± standard deviation (SD) unless otherwise indicated.