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Cellular Biology |
Is Required for PDE4, not PDE3, Activity in Subcellular Microdomains Containing the Sarcoplasmic Reticular Calcium ATPase in CardiomyocytesFrom the Departments of Physiology and Medicine, the Heart & Stroke Richard Lewar Centre, and the Division of Cardiology at the University Health Network (B.-G.K., D.Z., I.L.-S., P.H.B.), University of Toronto; the Departments of Pharmacology & Toxicology (L.S.W., D.H.M.), Queens University, Kingston; and the Departments of Physiology and Biophysics (S.C., S.R.W.C.), University of Calgary, Canada.
Correspondence to Peter H. Backx, DVM, PhD, Professor, 150 College St, Toronto, ON, M5S 3E2, Canada. E-mail p.backx{at}utoronto.ca
| Abstract |
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–deficient (PI3K
–/–) mice have enhanced cardiac contractility attributable to cAMP-dependent increases in sarcoplasmic reticulum (SR) Ca2+ content and release but not L-type Ca2+ current (ICa,L), demonstrating PI3K
locally regulates cAMP levels in cardiomyocytes. Because phosphodiesterases (PDEs) can contribute to cAMP compartmentation, we examined whether the PDE activity was altered by PI3K
ablation. Selective inhibition of PDE3 or PDE4 in wild-type (WT) cardiomyocytes elevated Ca2+ transients, SR Ca2+ content, and phospholamban phosphorylation (PLN-PO4) by similar amounts to levels observed in untreated PI3K
–/– myocytes. Combined PDE3 and PDE4 inhibition caused no further increases in SR function. By contrast, only PDE3 inhibition affected Ca2+ transients, SR Ca2+ loads, and PLN-PO4 levels in PI3K
–/– myocytes. On the other hand, inhibition of PDE3 or PDE4 alone did not affect ICa,L in either PI3K
–/– or WT cardiomyocytes, whereas simultaneous PDE3 and PDE4 inhibition elevated ICa,L in both groups. Ryanodine receptor (RyR2) phosphorylation levels were not different in basal conditions between PI3K
–/– and WT myocytes and increased in both groups with PDE inhibition. Our results establish that L-type Ca2+ channels, RyR2, and SR Ca2+ pumps are regulated differently in distinct subcellular compartments by PDE3 and PDE4. In addition, the loss of PI3K
selectively abolishes PDE4 activity, not PDE3, in subcellular compartments containing the SR Ca2+-ATPase but not RyR2 or L-type Ca2+ channels.
Key Words: cardiomyocytes PI3K
PDE3 PDE4 excitation-contraction-coupling
| Introduction |
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and PI3K
, which are members of PI3K subclass IA and IB, respectively, are the two main isoforms expressed in cardiomyocytes.1 Whereas PI3K
regulates heart growth,2 PI3K
has emerged as an important regulator of cardiac contractility and cardiac excitation-contraction coupling (ECC)3–7 by regulating basal cAMP levels3–5,8 and phospholamban (PLN) phosphorylation.3,5 We recently established that cardiomyocytes lacking PI3K
have cAMP-dependent increases in sarcoplasmic reticulum (SR) Ca2+ load and release without changes in L-type Ca2+ current (ICa,L),7,9 which is a prototype for regulation by cAMP-dependent protein kinase A (PKA) (see review8). Although the basis for the cAMP compartmentation in PI3K
-deficient mice is unclear, phosphodiesterases (PDEs) are a family of enzymes that are critical components of macromolecular complexes involved in the subcellular compartmentation of cAMP-PKA signaling8,10–12 by locally hydrolyzing cAMP or cGMP.13,14 For instance, cardiac-specific overexpression of human adenylate cyclase type 8 (AC8) in mice enhances cAMP levels, contractility, and Ca2+ transient, without affecting ICa,L15 because of PDE-based compartmentation of cAMP hydrolysis.10 Although the dominant PDEs regulating cAMP-PKA in heart are PDE3A and several members of the PDE4 family,16,17 a recent study reported that PDE3B activity is eliminated in PI3K
–/–-deficient hearts5,6 and that PI3K
stimulates PDE3B,5,18 even though PDE3B is primarily expressed in vascular smooth muscle cells and not in cardiomyocytes.13,19
The aim of this study was to elucidate the involvement of PDEs in the regulation of L-type Ca2+ channels and SR Ca2+ handling by PI3K
. Our results demonstrate that both PDE3 and PDE4 activities are required in mouse myocardium to maintain cAMP-PKA signaling at baseline levels within microdomains containing SR Ca2+ pumps and RyR2, but not in microdomains surrounding L-type Ca2+ channels. In addition, the loss of PI3K
abolishes PDE4, but not PDE3B, activity in microdomains containing SR Ca2+ pumps.
| Materials and Methods |
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–/– mice has previously been described20 (see supplemental materials, available online at http://circres.ahajournals.org).
Electrophysiology and SR Ca2+ Content
ICa,L was measured at room temperature (22°C, 1 mL min–1) with whole-cell patch-clamp technique21 under voltage-clamp mode, whereas the SR Ca2+ content was estimated by integrating the Na+-Ca2+ exchanger current (INCX) induced by brief (10 sec) applications of 20 mmol/L caffeine, as previously described7 (see supplemental materials).
Fluorescence
Voltage-clamped myocytes were loaded via the patch-pipette with fluo-3, 5K+ salt to record Ca2+ transients simultaneously to ICa,L, as previously described7 (see supplemental materials).
Western Blots
The phosphorylation levels of PLN and cardiac RyR2 were measured as previously described.3,22 We measured RyR2 phosphorylation at position S2030 because, unlike S2808, S2030 shows very low baseline phosphorylation.22 (see supplemental materials).
Statistics
Statistical significance was assessed using a 1-way analysis of variance (ANOVA) followed by either a Student Neuman-Keuls test or a Kruskal-Wallis test when the data were nonparametric. Paired t tests were used when comparing results from the same cardiomyocyte. P<0.05 was considered statistically significant. Data are presented as mean±SEM.
| Results |
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on cAMP compartmentation in vicinity of the SR. Figure 1 shows that perfusion of myocytes with milrinone for 8 minutes, at doses capable of selectively inhibiting PDE3,13,26 increased amplitudes and accelerated decay rates (Table) of Ca2+ transients in both WT and PI3K
–/– myocytes, establishing that PDE3 is active in PI3K
–/–. To confirm that the effects of milrinone were selective,26 the PDE3 inhibitor, cilostazol, at doses that selectively inhibit PDE3,26 yielded identical results to milrinone (supplemental Table I). Furthermore, 1 µmol/L milrinone had no effect, whereas the effects of 100 µmol/L milrinone were indistinguishable from 10 µmol/L milrinone (supplemental Table I).
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In contrast, rolipram application, at doses that selectively inhibit PDE4,13 had no effect on Ca2+ transients in PI3K
–/– myocytes, while enhancing the amplitude and decay rates of fluo-3 fluorescence in WT myocytes to levels indistinguishable from untreated PI3K
–/– myocytes (Figure 2 and Table). These findings suggest that PDE4 activity is lost in PI3K
–/– myocytes. As expected from pharmacological studies,19 1 µmol/L rolipram had no effect (supplemental Table I), whereas 100 µmol/L rolipram had similar effects to those observed with 10 µmol/L (Table S1), demonstrating specificity for PDE4 inhibition.
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The changes in F/F0 ratios induced by PDE inhibition were not related to cell shortening (which was as high as 12%, data not shown), because cell shortening leads to small underestimations of the Ca2+ transient amplitudes (ie, about 6%, data not shown). Thus, the elevated cell shortening observed with PDE3 and PDE4 inhibition cannot underlie the increased amplitudes or accelerated kinetics of the F/F0 ratios observed (see supplemental materials).
To assess the effects of PDEs inhibition on ICa,L, we measured ICa,L both at 8 minutes after membrane rupture in the absence of drug and again after 8 minutes of drug application (ie, 16 minutes after membrane rupture). PDE3 inhibition did not affect (P>0.5) ICa,L amplitudes (Figure 1B) and did not change either the maximum conductance of ICa,L (ie, Gmax) in WT myocytes (112±14 pS/pF control versus 98±10 pS/pF milrinone, n=7) and PI3K
–/– myocytes (117±5 pS/pF control versus 111±9 pS/pF milrinone, n=8) or voltage for half-maximal activation (V1/2) of ICa,L (supplemental Table I). Milrinone did, however, accelerate the Ca2+-dependent phase of ICa,L inactivation (ie,
fast) in both groups (Table), consistent with increased Ca2+ transients7,8 (see below). The absence of ICa,L changes were not caused by rundown because no differences in ICa,L were observed when comparisons were made between treated and untreated myocytes 16 minutes after membrane rupture (supplemental Figure I).
PDE4 inhibition also did not affect ICa,L (Figure 2B). Indeed, rolipram did not change (P>0.5) either Gmax of ICa,L in WT myocytes (107±4 pS/pF control versus 94±6 pS/pF rolipram, n=6) and PI3K
–/– (115±9 pS/pF control versus 101±11 pS/pF rolipram, n=8) myocytes or V1/2 of ICa,L (Table S1). Rolipram did, however, abbreviate
fast in WT myocytes, but not in PI3K
–/– myocytes (Table), because of secondary effects on Ca2+ transients (See below). Again, no differences in ICa,L amplitudes were observed 16 minutes after membrane rupture between myocytes treated with PDE4 inhibitors and untreated myocytes (supplemental Figure I).
Because SR Ca2+ release strongly affects ICa,L via Ca2+-mediated inactivation, the effects of PDEs inhibition could be partially masked by simultaneous changes in Ca2+ transients. Indeed, the fast component of the inactivation rate of ICa,L (ie,
fast), which reflects Ca2+-mediated inactivation, correlated strongly with Ca2+ transient amplitudes (Table). Thus, ICa,L measurements were repeated in myocytes dialyzed with 4 mmol/L EGTA to suppress SR Ca2+ release.27 Although EGTA does not eliminate Ca2+-mediated inactivation,28 it did abolish differences in
fast as expected.27 With EGTA in the pipette, PDE3 or PDE4 inhibition alone did not affect ICa,L amplitudes or Gmax in either WT or PI3K
–/– myocytes (data not shown).
The results above suggest that PDEs regulate baseline cAMP levels in subcellular compartments containing the SR, but not L-type Ca2+ channels, and that PI3K
is required for PDE4 activity in the SR compartment. To more directly investigate SR function, SR Ca2+ content was measured in myocytes dialyzed with clamped free Ca2+ concentrations (
75 nmol/L). After 8 minutes of dialysis, caffeine (20 mmol/L) was applied to induce SR Ca2+ release, allowing SR Ca2+ content to be measured by integrating the forward-mode NCX current (
INCX).29 Figure 3 shows that, without PDEs inhibitors, the
INCX was higher (P<0.05) in PI3K
–/– compared with WT myocytes. Milrinone increased
INCX in both groups, whereas PDE4 inhibition only increased
INCX in WT myocytes. Decay times for caffeine-induced INCX were not different between the groups (data not shown), suggesting that INCX densities were not detectably altered by PI3K
ablation.
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Consistent with the observed differences in SR Ca2+ content, the PLN-PO4/PLN ratio was elevated in PI3K
–/– compared with WT myocytes (Figure 3C and 3D). PDE3 inhibition increased PLN-PO4/PLN in both groups, whereas PDE4 inhibition enhanced this ratio in WT myocytes only. Although alterations in PLN-PO4 can explain the functional differences between the various groups, RyR2 phosphorylation could also contribute to enhanced SR Ca2+ release.30 Under basal conditions, RyR2-PO4 levels at position S2030, expressed as a fraction of the maximal phosphorylation achieved with isoproterenol treatment, did not differ (P=0.6) between WT (0.06±0.02, n=4) and PI3K
–/– (0.04±0.02, n=4) myocytes (Figure 4). On the other hand, PDE3 or PDE4 inhibition alone increased (P<0.05) RyR2-PO4 levels about 2 to 3 times in both groups, revealing that the loss of PI3K
does not abolish PDE4 activity in junctional SR microdomains containing RyR2, unlike SERCA2a-containing compartments.
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Because cAMP inhibitors reduce Ca2+ transients and SR Ca2+ content in PI3K
–/– myocytes,7,8 but not WT, our findings support a model (Figure 6A) where both PDE3 and PDE4 activities are required to maintain cAMP at basal levels in a common microdomains containing SERCA2a-PLN, with PI3K
being necessary for PDE4 activity. This model predicts that Ca2+ transients in WT and PI3K
–/– myocytes should be indistinguishable when PDE3 and PDE4 are inhibited simultaneously. However, Figure 5A shows that Ca2+ transients in WT myocytes treated with combined PDE3 and PDE4 inhibitors were not different from those with PDE3 or PDE4 inhibition. Moreover, with combined PDE3 and PDE4 inhibition, Ca2+ transients in WT myocytes were below those observed in PI3K
–/– myocytes. On the other hand, Ca2+ transients in PI3K
–/– myocytes with combined PDE3 and PDE4 inhibition were the same as those with PDE3 inhibition alone. These observations could be explained if other PI3K
-regulated PDEs also influence cAMP levels in the SR subdomain. However, Ca2+ transients with global inhibition of PDEs using IBMX (50 µmol/L) were identical to those observed when PDE3 and PDE4 were inhibited simultaneously (Table). Taken together, these results suggest that multiple microdomains with distinct cAMP regulation exist in the SR subcellular compartment (see Discussion).
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When Ca2+ transients were present, combined inhibition of PDE3 and PDE4 did not increase (P=0.6) Gmax for ICa,L in WT myocytes but increased Gmax (P<0.05) in PI3K
–/– (Figure 5A). With EGTA in the pipette, combined PDE3 and PDE4 inhibition increased (P<0.001) Gmax by 63±9% and shifted (P<0.001) V1/2 from –12.5±0.8 mV to–20.7±0.9 mV in PI3K
–/–, while increasing (P<0.05) Gmax by only 15±10% and modestly shifting (P<0.05) V1/2 from–11.4±0.8 mV to –17.6±2.0 mV in WT myocytes. The larger increases in ICa,L observed when EGTA was included in the pipette (Figure 5B) may be related to reductions in either Ca2+-dependent inhibition of AC isoforms31 or Ca2+-mediated ICa,L inactivation, as discussed below.
| Discussion |
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–/– mice results from increased SR Ca2+ cycling without changes in ICa,L.3,7,8 In this study we found that both PDE3 and PDE4 activities are required in mouse myocardium to maintain cAMP-PKA signaling at baseline levels within microdomains containing SR Ca2+ pumps and RyR2, but not in microdomains surrounding L-type Ca2+ channels. In addition, the loss of PI3K
abolishes PDE4 activity in microdomains containing SR Ca2+ pumps. The increased SR Ca2+ content as well as elevated Ca2+ transient amplitudes and relaxation rates observed with either PDE3 and PDE4 inhibition in WT myocytes are consistent with previous studies.13,19,26,32–35 The Ca2+ changes with PDE inhibition appeared to result from local cAMP elevations because they were tightly linked to increased PLN-PO4/PLN ratios without alterations in ICa,L. It is conceivable that increased RyR2-PO4 levels also contribute to the changes in Ca2+ homeostasis observed with PDE inhibition because RyR2 phosphorylation enhances SR Ca2+ leak12 and release.30 However, RyR2 phosphorylation is predicted to decrease SR Ca2+ loads and to have little effect on Ca2+ transient relaxation, contrary to our observations. Importantly, because PDE4 and PDE3 inhibition alone had similar effects on Ca2+ cycling and because cAMP antagonists dont affect Ca2+ cycling in mouse myocytes at baseline,7,8 our results establish that PDE3 and PDE4 enzymes are equally important in maintaining the cAMP at basal levels in microdomains containing SERCA2a-PLN. This conclusion is consistent with the high expression levels of PDE3A and PDE4D we observed in mouse cardiomyocytes, as reported previously13,19 as well as with the ability of PDE4D to coimmunoprecipitate with SERCA2a (supplemental Figure II). Moreover, PDE3A can be isolated from cardiac SR microsomal fractions,36,37 and PDE3 inhibition increases SERCA2a activity36,37 in cardiomyocytes.
A rather unexpected finding in our studies was the inability of combined PDE3 and PDE4 to alter Ca2+ transients beyond that observed with PDE3 or PDE4 inhibition alone. These observations could be explained by several mechanisms that are not mutually exclusive. For example, other PDEs isoforms could assist in the locally controlling cAMP hydrolysis. But this seems unlikely, because global PDE inhibition with IBMX produced effects identical to those observed with combined PDE3-PDE4 inhibition. Alternatively, it is also conceivable that the interactions between the PDEs are complicated via feedback regulation involving increased PDE3 and PDE4 activities by PKA-dependent phosphorylation.13,19,23,38 However, this type of interaction should enhance, not reduce, the effects of combined or global inhibition of PDEs. A more plausible explanation would be that, under basal conditions, more than 1 local pool of cAMP exists in microdomains containing target SERCA2a-PLN effectors. The precise characteristics of cAMP regulation in these pools are undoubtedly complex depending on the distribution and enzyme kinetics of PDE3 and PDE4 as well as the local cAMP production,39 which is also highly compartmentalized.40 For example, the EC50 for cAMP hydrolysis by PDE3 (ie, 0.1 to 0.5 µmol/L) is
10-fold higher than for PDE4 (0.5 to 4 µmol/L),13,19 thereby allowing PDE3 to dominate cAMP hydrolysis at low cAMP concentrations compared with PDE4. Clearly, further studies will be needed to fully identify the molecular and structural basis for the subcellular regulation of SR function by PDE3 and PDE4.
Our results demonstrate that Ca2+ transients, SR Ca2+ content, and PLN-PO4 levels were identical between PI3K
–/– myocytes under basal conditions and WT myocytes after PDE4 inhibition, and were unaffected in PI3K
–/– myocytes by PDE4 inhibition either under baseline conditions or when PDE3 was inhibited. These observations reveal that PDE4 activity is absent in the SR subdomains containing SERCA2a-PLN of PI3K
–/– myocytes. These results are surprising because previous studies concluded that the loss of PI3K
protein, but not of its enzymatic activity, abolishes PDE3B activity in the myocardium.5 However, we were unable to detect PDE3B expression in mouse cardiomyocytes (supplemental Figure II), consistent with previous reports,13,19 and a recent study found that PI3K
binding does not activate PDE3B.18 Furthermore, ablation of the lipid phosphatase PTEN increases cardiac PIP3 and impairs cardiac contractility3 and these effects of PTEN disruption were abolished by PI3K
deletion,3 suggesting that PIP3 generation by PI3K
is an important factor in the regulation of cardiac contractility.
Interestingly, Ca2+ transients, SR Ca2+ loads, and PLN-PO4 were greater in PI3K
–/– myocytes after PDE3 inhibition than in WT myocytes with combined PDE3-PDE4 inhibition. Given the inability of combined PDE3-PDE4 inhibition in WT cardiomyocytes to alter Ca2+ cycling and PLN-PO4 levels beyond that observed with PDE3 or PDE4 inhibition alone, one would anticipate that PDE3 inhibition in PI3K
–/– myocytes would have minimal impact. These unanticipated findings could arise if PDE4 activity was not completely inhibited in WT myocytes by 10 µmol/L rolipram.41 However, 10-fold higher doses of rolipram, which fully inhibit PDE4,41 had no further effect on Ca2+ transient in WT myocytes. Alternatively as discussed above, these results could reflect the presence of multiple cAMP pools with complex distribution patterns of PDEs and cAMP production. In fact, our results in WT and PI3K
–/– mice support a model wherein there are two pools of cAMP in SR microdomains containing SERCA2a/PLN (Figure 6). In one pool, both PDE3 and PDE4 activities are required to maintain cAMP levels at basal levels. In the second pool, PDE3 activity is necessary to stave off elevations in cAMP arising from increased local cAMP production, as shown previously in PI3K
-deficient myocardium as a consequence of reduced local G
-i activity6 and increased AC activity.
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Although no differences in ICa,L amplitudes were observed between PI3K
–/– and WT myocytes, the inactivation rates of ICa,L.7,8 were accelerated in PI3K
–/– myocytes, which can be attributed to increased Ca2+-mediated inactivation secondary to elevated Ca2+ transients.42 To eliminate the complicating effects of Ca2+ transients on ICa,L, we dialyzed myocytes with high levels of EGTA. Although EGTA does not eliminate Ca2+-mediated inactivation,28 it successfully eliminated the effects of SR Ca2+ release on ICa,L in our studies. When WT myocytes were dialyzed with EGTA, PDE3 or PDE4 inhibition alone did not affect ICa,L whereas combined PDE3-PDE4 inhibition induced modest ICa,L increases (
15% at –10mV), as reported previously.16,17 Combined PDE3-PDE4 inhibition in WT myocytes shifted V1/2 to negative voltages without affecting the Gmax, verifying that V1/2 and Gmax for ICa,L can be separately regulated.43 Thus, in microdomains containing L-type Ca2+ channels, either PDE3 or PDE4 activity alone is sufficient to maintain cAMP at basal levels. Several explanations could account for these observations. For example, because basal ICa,L is unchanged by cAMP antagonists,7,8 the inability of PDE3 or PDE4 inhibition alone to alter ICa,L could arise because of low basal cAMP production in ICa,L microdomains or because high cAMP levels are required to enhance ICa,L, or both. In this respect, it is conceivable that cAMP levels were in fact elevated in ICa,L microdomains but did not rise to levels required to modulate ICa,L. Alternatively, the ICa,L microdomains could possess high activity of other PDEs isoforms, although this seems unlikely because IBMX enhanced ICa,L by similar amounts as combined PDE4 and PDE3 inhibition in WT myocytes (data not shown).
The pattern of ICa,L regulation in PI3K
–/– myocytes was similar to WT myocytes, confirming that cAMP is regulated in ICa,L microdomains by both PDE3 and PDE4. Interestingly, because PDE3 inhibition alone did not increase ICa,L, we conclude that PDE4 activity is not abolished by PI3K
ablation in ICa,L microdomains, unlike subcompartments containing SERCA2a. The molecular basis for these differences between the SERCA2a and ICa,L subdomains is unclear, but we have found in preliminary studies that neither PDE3B nor PDE4D coimmunoprecipitate with the
1C subunit of the L-type Ca2+ channel. Moreover, combined PDE3-PDE4 inhibition increased ICa,L in PI3K
–/– far more (
2-fold) than in WT myocytes, suggesting that, as in microdomains containing SERCA2a, microdomains containing ICa,L in PI3K
–/– myocytes have higher cAMP levels, possibly resulting from decreased G
-i mediated inhibition of AC activity.6 Alternatively, PDE3 and PDE4 families have multiple subisoforms which can be localized differentially in cardiomyocytes.17 Unfortunately, no pharmacological tools exist currently to dissect contributions of separate members of the PDE3 or PDE4 families. The molecular and anatomical basis for PDEs regulation of ICa,L will clearly require further studies.
Another important target of cAMP-dependent PKA phosphorylation is RyR2,22 which can be phosphorylated at positions S2808 and S2030.22 Previous results have established that, unlike S2808, S2030 shows very low baseline phosphorylation levels22 and is phosphorylated by PKA, not CaMKinase. Therefore, we assessed the RyR2 phosphorylation status at position S2030. As with PLN-PO4 and Ca2+ homeostasis, PDE3 and PDE4 are both required to maintain basal RyR2-PO4 levels in WT myocytes. These findings are not unexpected given the colocalization of these proteins in the SR, particularly the junctional SR.30 However, unlike SERCA2a-PLN and Ca2+ homeostasis, PDE4 activity in subcellular compartments containing the RyR2 does not require PI3K
, establishing that PI3K
s involvement in the PDE4-dependent regulation of the SR function is unique to SERCA2a-PLN. This seems somewhat surprising because PDE4D coassembles with both SERCA2a and RyR2,12 and it will be interesting to determine whether PI3K
is in the macromolecular complex of signaling molecules that associates with RyR2.30
Our results have several important clinical implications. For example, a prominent feature of diseased myocardium is reduced Ca2+ transients resulting from decreased SR Ca2+ uptake, without changes in ICa,L density.44–46 This pattern is the opposite to that seen in PI3K
–/– mice suggesting that increased PI3K
activity may contribute to impaired contractility in heart disease3,4,47–50 by stimulating PDE4 activity and reducing Ca2+ uptake in the SR. This suggestion is consistent with the elevated PI3K
activity and expression,5,47 as well as increased PDE4 activity, observed in heart disease.51 These effects are expected to accentuate the impaired Ca2+ handling and contractility in heart disease46 originating from β-adrenergic receptor downregulation, enhanced G
-i activity, and reduced SERCA2a expression. Clearly, future studies will be required to fully assess the contribution of PI3K
-mediated changes in local cAMP to the pathogenesis of heart disease.
| Acknowledgments |
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Sources of Funding
This study was supported by Canadian Institutes for Health Research (CIHR) operating grant to P.H.B. P.H.B. and D.H.M. are Career Investigators with the Heart and Stroke Foundation (HSF) of Ontario. B.-G.K. held fellowships from HSF of Canada and TACTICS-CIHR program (University of Toronto).
Disclosures
None.
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