Ischemia and reperfusion–elicited tissue injury contributes to morbidity and mortality in a wide range of pathologies, including myocardial infarction, ischemic stroke, acute kidney injury, trauma, circulatory arrest, sickle cell disease and sleep apnea. Ischemia-reperfusion injury is also a major challenge during organ transplantation and cardiothoracic, vascular and general surgery. An imbalance in metabolic supply and demand within the ischemic organ results in profound tissue hypoxia and microvascular dysfunction. Subsequent reperfusion further enhances the activation of innate and adaptive immune responses and cell death programs. Recent advances in understanding the molecular and immunological consequences of ischemia and reperfusion may lead to innovative therapeutic strategies for treating patients with ischemia and reperfusion–associated tissue inflammation and organ dysfunction.

Background— Ecto-5′-nucleotidase (CD73)–dependent adenosine generation has been implicated in tissue protection during acute injury. Once generated, adenosine can activate cell-surface adenosine receptors (A 1 AR, A 2A AR, A 2B AR, A 3 AR). In the present study, we define the contribution of adenosine to cardioprotection by ischemic preconditioning. Methods and Results— On the basis of observations of CD73 induction by ischemic preconditioning, we found that inhibition or targeted gene deletion of cd73 abolished infarct size-limiting effects. Moreover, 5′-nucleotidase treatment reconstituted cd73 −/− mice and attenuated infarct sizes in wild-type mice. Transcriptional profiling of adenosine receptors suggested a contribution of A 2B AR because it was selectively induced by ischemic preconditioning. Specifically, in situ ischemic preconditioning conferred cardioprotection in A 1 AR −/− , A 2A AR −/− , or A 3 AR −/− mice but not in A 2B AR −/− mice or in wild-type mice after inhibition of the A 2B AR. Moreover, A 2B AR agonist treatment significantly reduced infarct sizes after ischemia. Conclusions— Taken together, pharmacological and genetic evidence demonstrate the importance of CD73-dependent adenosine generation and signaling through A 2B AR for cardioprotection by ischemic preconditioning and suggests 5′-nucleotidase or A 2B AR agonists as therapy for myocardial ischemia.

Studies of metabolic adaptation during environmental stress have broad applications to human disease. Adenosine signaling has been implicated in cardiac adaptation to limited oxygen availability. Serendipitously, a wide search for adenosine receptor A2b (Adora2b)-elicited cardio-adaptive responses identified the circadian rhythm protein period2 (Per2). Subsequent pharmacologic and genetic studies confirmed Adora2b-dependent stabilization of Per2 during myocardial ischemia. Functional studies of myocardial ischemia in Per2−/− mice revealed larger infarct sizes and abolished cardio-protection by ischemic preconditioning. Metabolic studies during myocardial ischemia uncovered a limited ability of Per2−/− mice to utilize carbohydrates via oxygen-efficient glycolysis. These metabolic alterations were associated with a failure in Per2−/− mice to stabilize hypoxia-inducible-factor Hif1a. Moreover, cardiac stabilization of Per2 via light-exposure transcriptionally enhanced glycolysis, and provided period-specific cardio-protection from ischemia. Together, these studies identify Per2 as key regulator of ischemia tolerance through reprogramming of cardiac metabolism and implicate Per2 as novel therapeutic modality during acute myocardial ischemia.