Cardiomyocyte cell death occurring during myocardial reperfusion (reperfusion injury) contributes to final infarct size after transient coronary occlusion. Different interrelated mechanisms of reperfusion injury have been identified, including alterations in cytosolic Ca 2+ handling, sarcoplasmic reticulum-mediated Ca 2+ oscillations and hypercontracture, proteolysis secondary to calpain activation and mitochondrial permeability transition. All these mechanisms occur during the initial minutes of reperfusion and are inhibited by intracellular acidosis. The cGMP/PKG pathway modulates the rate of recovery of intracellular pH, but has also direct effect on Ca 2+ oscillations and mitochondrial permeability transition. The cGMP/PKG pathway is depressed in cardiomyocytes by ischaemia/reperfusion and preserved by ischaemic postconditioning, which importantly contributes to postconditioning protection. The present article reviews the mechanisms and consequences of the effect of ischaemic postconditioning on the cGMP/PKG pathway, the different pharmacological strategies aimed to stimulate it during myocardial reperfusion and the evidence, limitations and promise of translation of these strategies to the clinical practice. Overall, the preclinical and clinical evidence suggests that modulation of the cGMP/PKG pathway may be a therapeutic target in the context of myocardial infarction.
LINKED ARTICLESThis article is part of a themed section on Conditioning the Heart -Pathways to Translation. To view the other articles in this section visit http://dx.doi. org/10.1111/bph.2015.172.issue-8 Abbreviations AMI, acute myocardial infarction; ANP, atrial natriuretic peptide; BH4, tetrahydrobiopterin; CaMK, Ca 2+ /calmodulin-dependent PK; eNOS, endothelial NOS; GIK, glucose-insulin-potassium; GLP-1, glucagon-like peptide-1; GSK3β, glycogen synthase kinase-3β; mPTP, mitochondrial permeability transition pore; NHE, Na+/H + exchanger; NP, natriuretic peptide; ODQ, 1H- [1,2,4]oxadiazolo [4,3-a]quinoxalin-1-one; PCI, percutaneous coronary intervention; pGC, particulate GC; pHi, intracellular pH; PLB, phospholamban; PoCo, ischaemic postconditioning; PreC, ischaemic preconditioning; RIC, remote ischaemic conditioning; RISK, reperfusion injury salvage kinases; ROS, reactive oxygen species; SERCA, sarcoplasmic reticulum Ca
Ischaemia/reperfusion injuryCardiomyocyte death is the main cause of the mortality and morbidity in patients with ischaemic heart disease, the leading cause of death in the global world population. It occurs mainly during the acute coronary syndrome, and in particular during myocardial infarction with ST-segment elevation, for which the main treatment is prompt reperfusion. There is solid evidence supporting that part of cell death, secondary to transient coronary occlusion, occurs upon restoration of coronary blood flow, a phenomenon known as reperfusion injury (Piper et al., 1998;Yellon and Hausenloy, 2007). The mechanisms responsible for cell death during myocardial reperfusion are complex but progressively better k...