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Circulation Research. 1999;85:137-146

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(Circulation Research. 1999;85:137-146.)
© 1999 American Heart Association, Inc.


Original Contribution

Mechanical Stretch and Angiotensin II Differentially Upregulate the Renin-Angiotensin System in Cardiac Myocytes In Vitro

Ricky Malhotra, Junichi Sadoshima, Frank C. Brosius, III, Seigo Izumo

From the Cardiovascular Research Center (R.M., J.S., S.I.) and Department of Internal Medicine, Division of Nephrology (R.M., F.C.B.), University of Michigan Medical Center, Ann Arbor, Mich; Cardiovascular and Pulmonary Research Institute (J.S.), Allegheny University of the Health Sciences, Pittsburgh, Pa; and Cardiovascular Division (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.

Correspondence to Seigo Izumo, Cardiovascular Division, Beth Israel Deaconess Medical Center, SL-201, 330 Brookline Avenue, Boston, MA 02215 ( E-mail sizumo{at}caregroup.harvard.edu), or Junichi Sadoshima, Cardiovascular and Pulmonary Research Institute, Allegheny University of the Health Sciences, Pittsburgh, PA 15212 (


*    Abstract
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*Abstract
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Abstract—Pressure overload in vivo results in left ventricular hypertrophy and activation of the renin-angiotensin system in the heart. Mechanical stretch of neonatal rat cardiac myocytes in vitro causes secretion of angiotensin II (Ang II), which in turn plays a pivotal role in mechanical stretch–induced hypertrophy. Although in vivo data suggest that the stimulus of hemodynamic overload serves as an important modulator of cardiac renin-angiotensin system (RAS) activity, it is not clear whether observed upregulation of RAS genes is a direct effect of hemodynamic stress or is secondary to neurohumoral effects in response to hemodynamic overload. Moreover, it is unclear whether activation of the local RAS in response to hemodynamic overload predominantly occurs in cardiac myocytes or fibroblasts or both. In the present study, we examined the effect of mechanical stretch on expression of angiotensinogen, renin, angiotensin-converting enzyme (ACE), and Ang II receptor (AT1A, AT1B, and AT2) genes in neonatal rat cardiac myocytes and cardiac fibroblasts in vitro. The level of expression of angiotensinogen, renin, ACE, and AT1A genes was low in unstretched cardiac myocytes, but stretch upregulated expression of these genes at 8 to 24 hours. Stimulation of cardiac myocytes with Ang II also upregulated expression of angiotensinogen, renin, and ACE genes, whereas it downregulated AT1A and did not affect AT1B gene expression. Although losartan, a specific AT1 antagonist, completely inhibited Ang II–induced upregulation of angiotensinogen, renin, and ACE genes, as well as stretch-induced upregulation of AT1A expression, it did not block upregulation of angiotensinogen, renin, and ACE genes by stretch. Western blot analyses showed increased expression of angiotensinogen and renin protein at 16 to 24 hours of stretch. The ACE-like activity was also significantly elevated at 24 hours after stretch. Radioligand binding assays revealed that stretch significantly upregulated the AT1 density on cardiac myocytes. Interestingly, stretch of cardiac fibroblasts did not result in any discernible increases in the expression of RAS genes. Our results indicate that mechanical stretch in vitro upregulates both mRNA and protein expression of RAS components specifically in cardiac myocytes. Furthermore, components of the cardiac RAS are independently and differentially regulated by mechanical stretch and Ang II in neonatal rat cardiac myocytes.


Key Words: stretch • cardiac myocyte • renin-angiotensin system • angiotensin II • radioligand binding


*    Introduction
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up arrowAbstract
*Introduction
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The renin-angiotensin system has been described as an endocrine regulator of cardiovascular physiology. However, a number of recent biochemical and molecular biological studies point to the existence of a local renin-angiotensin system in the heart.1 2 3 The principal mediator of the renin-angiotensin system is the vasoactive peptide angiotensin II (Ang II). Ang II has been extensively implicated in the development of cardiac hypertrophy associated with hemodynamic overload, myocardial infarction, and hypertension.4 5 6 Previous studies have demonstrated that mechanical stretch of cultured rat cardiac myocytes causes a rapid secretion of Ang II7 8 9 10 and that this autocrine production of Ang II plays a critical role in many, if not all, stretch-induced hypertrophic responses.7 8 We, and others, have reported that Ang II causes hypertrophic responses and activates multiple protein kinases in neonatal rat cardiac myocytes.8 11 12

Several in vivo studies have demonstrated that mRNA expression of cardiac angiotensinogen,4 13 angiotensin-converting enzyme (ACE),14 15 and Ang II type 1 and type 2 receptors16 17 18 (AT1 and AT2, respectively) are upregulated in response to pressure overload or after myocardial infarction in various animal species. Similarly, cardiac renin activity and renin mRNA are increased in experimental animals having volume-overloaded cardiac hypertrophy.19 20 In a canine model of right ventricular hypertrophy and failure caused by tricuspid valve occlusion and progressive pulmonary artery constriction, upregulation of ACE and AT2 mRNA was demonstrated recently.21

Although these results indicate that mRNA expression of cardiac renin-angiotensin system genes is affected in response to hemodynamic overload in vivo, it is not known whether upregulation of renin-angiotensin system genes is due to the direct effect of hemodynamic stresses or is secondary to neurohumoral effects caused by hemodynamic overload. The main goal of this study was, therefore, to examine whether mechanical stretch (up to 24 hours) directly affects expression of angiotensinogen, renin, ACE, and Ang II receptor subtype (AT1A, AT1B, and AT2) genes in neonatal rat cardiac myocytes using the in vitro model of stretch-induced cardiac hypertrophy.22 In addition, we also addressed the following questions. First, given that mechanical stretch of neonatal rat cardiac myocytes causes a rapid secretion of Ang II, and Ang II mediates many, if not all, aspects of cardiac hypertrophic responses,7 22 23 did the Ang II secreted by stretch regulate subsequent expression of cardiac renin-angiotensin system genes? Second, given that a number of cell types are present in the heart, with cardiac myocytes and fibroblasts being the predominant cell types, did activation of the local renin-angiotensin system in response to hemodynamic overload in vivo occur primarily in cardiac myocytes or fibroblasts or both? Therefore, we separately made myocyte and fibroblast cultures on deformable silicone substrates and examined the effect of mechanical stretch on expression of renin-angiotensin system genes in the individual cell types.

We report that mechanical stretch is sufficient to upregulate expression of the local renin-angiotensin system genes, including angiotensinogen, renin, ACE, and AT1A, predominantly in cardiac myocytes. In addition, we unexpectedly found that stretch-induced upregulation of angiotensinogen, renin, and ACE is mediated by an Ang II–independent mechanism.


*    Materials and Methods
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*Materials and Methods
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Materials
All culture reagents were purchased from GIBCO-BRL. All radiochemicals were obtained from DuPont-New England Nuclear. Losartan and PD123319 were generous gifts from DuPont Merck and Parke-Davis, respectively. Ang II was purchased from Peninsula Laboratories. All other chemicals were from Sigma.

Cell Culture
Primary cultures of neonatal rat cardiac myocytes were prepared as described.22 Cardiac myocytes were obtained from ventricular tissue of 1-day-old Wistar rats by 6 or 7 digestions, 15 minutes each, at 37°C in HEPES-buffered saline solution containing 0.1% collagenase IV, 0.1% trypsin, 15 µg/mL DNase I, and 1.0% chicken serum. The dissociated cells were collected by centrifugation and resuspended in DMEM/F-12 (GIBCO-BRL) (1:1, vol/vol) supplemented with 5% horse serum, 3 mmol/L pyruvic acid, 100 µmol/L ascorbic acid, 1 µg/mL transferrin, 10 ng/mL selenium, and 100 µg/mL ampicillin. To selectively enrich for cardiac myocytes, the differential attachment technique (preplating) for 1 hour was used. The resultant suspension of cardiac myocytes was plated onto the collagen-coated silicone sheet at a density of 1x105 cells/cm2. Bromodeoxyuridine at a final concentration of 0.1 mmol/L was added during the first 36 hours to prevent nonmyocyte proliferation. After 36 hours, the culture medium was changed to serum-free DMEM/F-12. This procedure normally resulted in contractile myocardial cell cultures with {approx}90% to 95% myocytes, as described previously.22 Highly enriched cultures of nonmyocytes (cardiac fibroblasts) were prepared by 2 passages of cells adhered to the culture dish during the preplating procedure.

Mechanical Stretch
The in vitro stretch device used in the present experiments has been previously described.22 A uniaxial strain was applied by stretching the silicone sheet in the Plexiglas support frame by 20%. All stretch experiments were performed 48 hours after changing the medium in cardiac myocyte and cardiac fibroblast cultures to serum-free medium.

Reverse Transcription–Polymerase Chain Reaction (RT-PCR)
Isolation and Analysis of RNA
Total cellular RNA was isolated from cardiac myocytes by harvesting the cells in 4 mol/L guanidinium thiocyanate, followed by ultracentrifugation through 5.7 mol/L cesium chloride solution.24 Genomic DNA was removed by incubation with RNase-free DNase (Promega) in 1x buffer (in mmol/L, Tris-HCl [pH 7.9] 40, NaCl 10, MgCl2 6, and CaCl2 10) at 37°C for 20 minutes. The mRNA was extracted with phenol/chloroform/isoamyl alcohol and precipitated with ethanol. The integrity of the RNA was checked by electrophoresis through 1% formaldehyde-containing agarose gels.

Reverse Transcription
One microgram of RNA sample was reverse transcribed in 1x PCR buffer (50 mmol/L KCl and 10 mmol/L Tris-HCl, pH 8.3) in the presence of 5 mmol/L MgCl2, 1 mmol/L dNTPs, 1 U/µL RNase inhibitor, 2.5 µmol/L random hexanucleotide primers, and 2.5 U/µL Moloney murine leukemia virus reverse transcriptase (Perkin Elmer). The tubes were initially incubated at room temperature for 10 minutes, and then the reverse transcription reaction was carried out at 42°C for 60 minutes, followed by denaturation at 99°C for 5 minutes and cooling at 5°C for 5 minutes.

Design of Primers
The cDNA regions of rat angiotensinogen, renin, ACE, AT1A, AT1B, and AT2 genes were amplified by the PCR of each gene. The PCR primers were designed in such a way that the sequences corresponding to the 2 primers were separated by introns. Thus, genomic DNA contamination, if present, in the PCR could be easily identified. The sequence of oligonucleotide primers used for PCR amplification of angiotensinogen, renin, ACE, AT1A, AT1B, and AT2 genes and tubulin is shown in the TableDown. AT1A and AT1B were distinguished by using oligonucleotide primers specific for the respective 3' noncoding region, as described previously.25


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Table 1. Design of Primers

Polymerase Chain Reaction
The 20-µL reverse transcription reactions were directly used for PCR amplifications of renin-angiotensin system and Ang II receptor genes. A typical PCR of 100 µL final volume was carried out in 1x PCR buffer (50 mmol/L KCl and 10 mmol/L Tris-HCl, pH 8.3) containing 2 mmol/L MgCl2, 2.5 units of AmpliTaq DNA polymerase (Perkin Elmer), and 0.15 µmol/L of the respective primers. The PCR amplification profile for each of the genes examined involved an initial denaturation step at 94°C/95°C for 30 seconds to 1 minute. The primer-annealing step for the renin-angiotensin system and Ang II receptor genes was as follows: angiotensinogen, 63°C for 60 seconds; renin, 62°C for 30 seconds; ACE, 55°C for 30 seconds; and AT1A, AT1B, and AT2, 58°C for 45 seconds. The PCR products were extended for 30 to 90 seconds at 72°C, with a final elongation step at 72°C for 7 minutes. The numbers of PCR cycles for the 6 genes examined were as follows: angiotensinogen, 30; renin, 35; ACE, 25; and AT1A, AT1B, and AT2, 30. The size of the final PCR product is shown in the TableUp. The PCRs were carried out in the Perkin Elmer thermal cycler 480. The PCR products were extracted with phenol/chloroform/isoamyl alcohol (25:24:1, vol/vol), and 10-µL products were analyzed in 1.5% to 2% agarose gels. To further ensure that RT-PCR products were not amplified from genomic DNA, all RNA samples were additionally amplified without reverse transcriptase. In all cases, PCR of RNA samples was negative in the absence of reverse transcriptase (data not shown).

PCR–Southern Blot Analysis
The specificity of PCR products was confirmed by Southern hybridization using a 5' end-labeled internal oligonucleotide probe. Briefly, the agarose gel was subjected to 20 to 30 minutes of successive treatment with denaturation (1.5 mol/L NaCl and 0.5 mol/L NaOH) and neutralizing (1.5 mol/L NaCl and 0.5 mol/L Tris-HCl, pH 7.0) solutions, followed by a distilled H2O rinse. The PCR products were transferred overnight to Hybond nylon N+ membranes (Amersham) in 10x SSC. The sequence of the oligonucleotide probes used in the present study is shown below:

The oligonucleotide probes (100 ng) were 5'-end labeled and purified on a nucleic acid chromatography system column (GIBCO-BRL), and they had a specific activity of >=2x109 cpm/µg. The membranes were prehybridized (4 to 6 hours) and hybridized (10x Denhardt's solution, 4x SSC, 10 mmol/L Tris-HCl [pH 7.5], 0.1% SDS, 1 mmol/L EDTA, and 100 µg/mL sheared and denatured salmon sperm DNA) for 10 to 12 hours at 20°C to 25°C below the estimated denaturing temperature of the respective oligonucleotide probes. The probe concentration used was 2 to 4x106 cpm/mL of hybridization buffer. After hybridization, the blots were washed 3 times at low stringency (2x SSC and 0.05% SDS at 22°C), followed by 2 washes at high stringency (4x SSC and 0.1% SDS at the respective hybridization temperature). Autoradiography was carried out at –70°C.

Linearity of PCR Amplification
To check whether our PCR conditions for the renin-angiotensin system genes were in the linear assay range, we performed experiments with varying amounts of total input RNA. As an internal control, we used primers for the ubiquitously expressed gene tubulin, which is coamplified along with the target RNA(s) of interest. Amplification of tubulin was monitored to determine sample-to-sample variations in RT and PCR conditions and the extent of degradation and recovery of RNA. Because of the relative abundance of tubulin expression in cells as compared with that of renin-angiotensin system genes, primers for tubulin were added to the PCR for only the last 22 cycles. A semiquantification of the renin-angiotensin system gene expression was achieved by the densitometric analysis of the signal strength obtained on the PCR-Southern autoradiograms. The densitometric score in the stretched state was expressed relative to a control or unstretched condition, which was arbitrarily fixed at 1. At fixed PCR cycle numbers, varying input RNA concentrations from 0.1 to 2.5 µg of all renin-angiotensin system genes resulted in a linear amplification range for each gene (Figure 1Down). These results indicate that our RT-PCRs were all performed in the linear range of the reaction.



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Figure 1. Linearity of PCR amplification. The linearity of RT-PCR to total input RNA (0.1 to 2.5 µg) for the renin-angiotensin system (angiotensinogen, renin, and ACE) and AT1A genes was examined. Each data point represents the mean of 2 independent observations. Straight lines represent best fit obtained by the linear regression analysis; r value indicates correlation coefficient.

Western Blot Analysis
Cardiac myocytes were grown on silicone membranes as described and stretched for 8 to 24 hours. The cells were rinsed with cold PBS (pH 7.4) and then scraped into hypotonic lysis buffer containing (in mmol/L) Tris (pH 7.4) 20, benzamidine 10, EDTA 10, ß-mercaptoethanol 5, phenylmethylsulfonyl fluoride (PMSF) 1, and 1 mg/mL leupeptin and 0.1 mg/mL aprotinin) for renin and radioimmunoprecipitation assay (RIPA) buffer (1x PBS, 1% NP-40, 0.5% sodium deoxycholate, 0.1% SDS, and protease inhibitors) for angiotensinogen detection. The samples were further homogenized and sedimented at 100 000g for 40 minutes at 4°C. The supernatants were collected and stored at –70°C.

Proteins (50 µg) from control and stretched lysates were fractionated on 12.5% (for renin) and 10% (for angiotensinogen) SDS-PAGE as described.12 Blots were blocked by incubation for 1 hour at room temperature with Blotto (10 mmol/L Tris-HCl [pH 8.0], 150 mmol/L NaCl, 5% nonfat dry milk, and 0.05% Tween-20). Mouse monoclonal antibody against rat angiotensinogen or renin (Swant, Swiss Antibodies) was diluted in Blotto (0.5 and 0.1 µg/mL, respectively) and incubated with the membranes overnight at 4°C. The blots were rinsed with TBS-T (10 mmol/L Tris-HCl [pH 8.0], 150 mmol/L NaCl, and 0.05% Tween-20) and incubated for 1 hour in Blotto with a 1:10 000 dilution of horseradish peroxidase–conjugated anti-mouse secondary antibodies. Detection was performed using enhanced chemiluminescence (Amersham) followed by autoradiography.

Measurement of ACE-Like Activity
The ACE-like activity was measured by hydrolysis of synthetic tripeptide substrate N-(3-[2-furyl]acrylol)phenylalanylglycylglycine followed by spectrophotometric determination of a decrease in absorbance at 340 nm as previously described.26 The ACE-like activity in the control and stretched cardiac myocytes samples was determined by comparing the sample reaction rate with that obtained with the ACE calibrator (Sigma).

Ang II Receptor Binding Assay
Radioligand binding assay for the Ang II receptor was performed as previously described.16 In addition, this assay was repeated on cardiac myocytes, which were highly enriched by centrifugation through Percoll gradient according to the method of Sheng et al.27 The cells were harvested in ice-cold buffer (0.25 mol/L sucrose and 25 mmol/L Tris, pH 7.5, containing 0.5 mmol/L EDTA, 0.5 mmol/L PMSF, 10 mg/L bacitracin, 4 µg/mL leupeptin, 4 µg/mL pepstatin, and 40 U/mL aprotinin [Trasylol]). The cells were subsequently disrupted with 2 freeze-thaw cycles and homogenized using a Polytron (twice for 30 to 60 seconds each). The homogenates were centrifuged twice at 10 000g for 10 minutes, and the supernatants were subjected to further centrifugation at 45 000g for 45 minutes. The pellet was resuspended in 25 mmol/L Tris, pH 7.5, containing 10 mmol/L MgCl2, 0.5 mmol/L PMSF, 4 µg/mL pepstatin, 4 µg/mL leupeptin, 40 U/mL aprotinin, and 10 mg/L bacitracin. For binding experiments, 25 µg of membrane protein was incubated in 150 µL of assay buffer (25 mmol/L Tris, pH 7.5, containing 10 mmol/L MgCl2; 2 g/L BSA; 10 mg/L bacitracin; the peptidase inhibitors antipain, N-rhamnopyranosyloxyhydroxyphosphinyl-Leu-Trp [Phosphoramidon], leupeptin, pepstatin, ubenimex [Bestatin], and amastatin, each at 1 µg/mL; and 0.5 mmol/L PMSF) at 22°C for 60 minutes with 0.05 to 10 nmol/L 125I-labeled Tyr4-Ang II ([125I]Tyr4-Ang II) to determine saturation binding. The reaction was stopped by the addition of 1 mL of ice-cold 25 mmol/L Tris, pH 7.5, and the mixtures were immediately filtered through a Bio-Rad microfiltration apparatus by vacuum filtration after an initial rinse with 1 g/L BSA. The filters were washed twice with 5 mL of 25 mmol/L Tris, pH 7.5, and the trapped radioactivity was measured in a gamma counter. Nonspecific binding (in the presence of 1 µmol/L Ang II) was subtracted from total binding. Binding to the AT1 and AT2 subtypes was estimated by subtracting the nonspecific binding from the maximum saturation binding with 5 nmol/L 125I-labeled Ang II ([125I]Ang II) after preincubation with 10 µmol/L PD123319 or 10 µmol/L losartan for 30 minutes at 22°C, respectively. Ang II receptor densities were calculated from the Scatchard analysis of the saturation binding curves.

Statistics
Data are given as mean±SEM. Statistical analysis was performed using ANOVA and an unpaired Student t test as appropriate. Significance was accepted at P<0.05.


*    Results
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*Results
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Mechanical Stretch Upregulates Angiotensinogen, Renin, ACE, and AT1A mRNAs
We examined the effect of stretch on mRNA expression of angiotensinogen, renin, ACE, and AT1A, AT1B, and AT2 genes in cultured neonatal rat cardiac myocytes. Cardiac myocytes were cultured under serum-free conditions, and a 20% uniaxial stretch was applied for 8, 16, and 24 hours. Control myocytes were also plated on the stretch dish and harvested without stretch. Expression of each gene was determined by RT-PCR. We included primers for tubulin in the PCR as an internal control. The linearity of the PCR was confirmed for each gene (Figure 1Up) as described in Materials and Methods. The specificity of each PCR band was determined by the size as well as by Southern hybridization with an end-labeled internal oligonucleotide probe. Figures 2Down and 3Down show the results of RT-PCR analyses. The basal expression of angiotensinogen, renin, and ACE mRNA was very low in unstretched myocytes. Mechanical stretch of 16- to 24-hour duration resulted in a 3- to 5-fold upregulation in the expression of all 3 genes examined, as revealed by densitometric analyses of the autoradiograms (Figure 2Down).



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Figure 2. Mechanical stretch of cardiac myocytes in vitro upregulates angiotensinogen, renin, and ACE. Total RNA (1 µg) was reverse transcribed, and the resultant cDNA was amplified with PCR using gene-specific primers. The specificity of PCR product was confirmed by Southern hybridization using end-labeled internal oligonucleotide probe as described in Materials and Methods. Primers for tubulin were used as an internal control. For renin gene expression, rat kidney RNA was used as a positive control. Southern hybridization of the PCR products for the renin-angiotensin system genes and ethidium bromide staining of tubulin PCR products are shown. The lower panels show the relative expression of the genes at different time intervals, obtained by densitometric analyses as described in Materials and Methods. The normalized value in the unstretched control was arbitrarily expressed as 1 unit. Data are mean±SEM of 4 separate experiments.



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Figure 3. The effect of stretch on Ang II receptor expression in neonatal rat cardiac myocytes. Total RNA (1 µg) was reverse transcribed, and the resultant cDNA was amplified with PCR using gene-specific primers. A, Autoradiogram depicting mechanical stretch–mediated upregulation of AT1A gene expression at 8 to 24 hours. B, No change is observed in AT1B mRNA expression after myocyte stretching. C, Apparent absence of the AT2 transcript in control and stretched conditions. Rat endothelial cell total RNA was used as a positive control for AT2 expression. Ethidium bromide staining of tubulin signals used as an internal control is also shown. Bottom panels, relative expression of the genes at different time intervals, obtained by densitometric analyses. Level of expression before stretch (at time 0) was expressed as 1 arbitrary unit. Data are mean±SEM of 4 separate experiments.

Stretch also upregulated expression of the AT1A gene. Increased (8- to 10-fold) expression of the AT1A gene was observed at as early as 8 hours after stretch was begun (Figure 3AUp). Interestingly, expression of the AT1B gene was not affected by stretch (Figure 3BUp). No RT-PCR signal for the AT2 transcript could be detected in cardiac myocytes or fibroblasts, although a distinct band was amplified from rat endothelial cell RNA (Figure 3CUp) used as a positive control for RT-PCR.28

Mechanical Stretch Also Upregulates Angiotensinogen and Renin Protein Expression and Increases ACE-Like Activities
To determine whether an increase in the mRNA expression of angiotensinogen, renin, and ACE genes by mechanical stretch is also translated into an increase in protein, we performed Western blot analyses using monoclonal antibodies specific for rat angiotensinogen and renin. We also measured the ACE-like activity in control and stretched conditions. Expression of both angiotensinogen and renin protein in control unstretched myocytes was undetectable. However, 16 to 24 hours of stretch significantly upregulated the protein expression of both angiotensinogen (Figure 4ADown) and renin (Figure 4BDown).



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Figure 4. Mechanical stretch of cardiac myocytes in vitro upregulates angiotensinogen and renin protein expression. Total protein (50 µg) was subjected to Western blot analysis using monoclonal antibodies specific for rat angiotensinogen and rat renin as described in Materials and Methods. A, Autoradiogram depicting mechanical stretch–mediated upregulation of angiotensinogen protein at 16 to 24 hours. Rat liver protein extract was used as a positive control for angiotensinogen. B, Increase is shown in renin protein expression at 24 hours of stretch. Rat kidney was used as a positive control for renin expression. MW indicates molecular weight. Data are representative of 2 independent experiments.

Furthermore, measurement of the ACE-like activity revealed that stretch of 24 hours significantly increased the ACE-like activity by almost 2-fold compared with that in control unstretched cardiac myocytes (unstretched control, 10.6±1.8 mU/106 cells; after 24 hours of stretching, 23.7±3.4 mU/106 cells [n=3], P=0.001).

Ang II Upregulates Angiotensinogen, Renin, and ACE but Downregulates AT1A Expression
We next examined whether Ang II, when exogenously applied, mimics the effect of stretch on expression of the renin-angiotensin system genes. Cells were grown on gelatin-coated dishes, serum starved, and stimulated with Ang II (1x10–7 mol/L) for various periods. Ang II caused a significant upregulation of angiotensinogen, renin, and ACE genes at 16 hours of stimulation. Ang II–induced upregulation of angiotensinogen, renin, and ACE genes was completely inhibited in the presence of the AT1 selective antagonist losartan (1 µmol/L) but not at all by the AT2 selective antagonist PD123319 (Figure 5Down), which suggests that Ang II–induced upregulation of angiotensinogen, renin, and ACE genes was mediated by AT1. In contrast, Ang II treatment significantly downregulated (by 70%) expression of AT1A, an effect that could be reversed by pretreatment of cells with losartan (Figure 5Down, right). Thus, both stretch and Ang II upregulate expression of angiotensinogen, renin, and ACE genes, whereas they differentially regulate mRNA expression of AT1A (upregulation by stretch and downregulation by Ang II).



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Figure 5. Effect of Ang II on expression of angiotensinogen, renin, ACE, and AT1A genes in neonatal rat cardiac myocytes. Cardiac myocytes in serum-free medium were stimulated with Ang II (1x10–7 mol/L) for 16 hours (added every 8 hours) in the presence or absence of losartan (1 µmol/L) or PD123319 (1 µmol/L). Expression of each gene was quantified by RT-PCR as described in Materials and Methods, and the level of gene expression was quantified by densitometric analyses. Level of gene expression in unstimulated myocytes was expressed as 1 arbitrary unit. All data shown are mean±SEM (n=3, except for AT1A [n=4]).

Stretch-Induced Upregulation of Angiotensinogen, Renin, and ACE Is Not Suppressed by the Ang II Receptor Antagonist
To determine whether mechanical stretch–induced upregulation of angiotensinogen, renin, and ACE genes is mediated by Ang II (which is secreted from cardiac myocytes by stretch), we examined the effect of losartan and PD123319 on stretch-induced upregulation of these genes. Cells were pretreated with each antagonist for 30 minutes, and then uniaxial stretch of 20% was applied for 16 hours. Unexpectedly, stretch-induced upregulation of angiotensinogen, renin, and ACE was not suppressed by losartan (1 µmol/L) or PD123319 (1 µmol/L) (Figure 6Down). This suggests that stretch-induced upregulation of angiotensinogen, renin, and ACE genes in vitro is mediated by Ang II–independent mechanisms. In contrast, the stretch-mediated upregulation of AT1A mRNA was completely suppressed by losartan (Figure 6Down, right).



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Figure 6. Effect of Ang II receptor blockade on stretch-induced upregulation of renin-angiotensin system gene expression. Cardiac myocytes grown on silicone membranes were stretched for 16 hours in the presence or absence of losartan (1 µmol/L) or PD123319 (1 µmol/L). Relative expression of renin-angiotensin system genes and AT1A mRNAs was obtained by RT-PCR, as described in Materials and Methods, followed by densitometric analyses. The level of gene expression in unstretched myocytes was taken as 1 arbitrary unit. Data are mean±SEM of 4 separate experiments.

It has been reported that tyrosine kinases highly sensitive to genistein (20 µmol/L) are responsible for stretch-induced upregulation of AT1 in cardiac myocytes.29 Thus, we explored whether genistein-sensitive tyrosine kinases are responsible for stretch-induced upregulation of renin-angiotensin system genes. Cardiac myocytes were treated with genistein (100 µmol/L), and then a uniaxial stretch of 20% was applied for 16 hours. Stretch-induced increases in AT1A mRNA expression were inhibited by genistein, which was consistent with the previous observation.29 Interestingly, however, stretch-induced upregulation of angiotensinogen, renin, and ACE genes was not suppressed by genistein (Figure 7Down). This indicates that stretch-induced upregulation of angiotensinogen, renin, and ACE genes are mediated by a genistein-insensitive mechanism distinct from that for AT1A upregulation.



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Figure 7. The effect of a tyrosine kinase inhibitor, genistein, on stretch-induced upregulation of the renin-angiotensin system gene expression. Cardiac myocytes grown on silicone membranes were stretched for 16 hours in the presence or absence of genistein (100 µmol/L). The relative expression of renin-angiotensin genes was obtained by RT-PCR, as explained in Materials and Methods, followed by densitometric analysis. The level of gene expression in unstretched myocytes was taken as 1 arbitrary unit. The data shown are mean of 2 independent experiments.

Mechanical Stretch Induces an Increase in AT1 Protein Expression
Our Ang II binding assay using [125I]Tyr4-Ang II demonstrated the presence of specific, saturable Ang II binding sites on neonatal rat ventricular myocyte membranes (Figure 8ADown). Saturation binding studies of [125I]Tyr4-Ang II to the myocyte membranes were performed using 0.01 to 10 nmol/L [125I]Ang II. These data showed the binding constant (Kd) of Ang II for AT1 and AT2 on cardiac myocytes to be 0.7 nmol/L, which is in close agreement with the previously reported Kd of the Ang II receptors of neonatal rat cardiac myocytes.30 31 The total Ang II receptor density (Bmax) in the stretched cells increased nearly 3-fold as compared with those in the control unstretched cells (206±3 versus 72±3 fmol/mg protein). To characterize AT1 and AT2 subtypes, a competition binding was performed using their respective antagonists. The specific [125I]Ang II binding insensitive to losartan or PD123319 (10 µmol/L each) was estimated to be AT2 and AT1 binding, respectively. The proportion of receptor subtypes was 71±4% for AT1 and 29±3% for AT2 in the membranes prepared from control cells. In the membranes prepared from cells stretched for 16 hours, expression of AT1 was significantly increased by >3-fold as compared with those of controls, but that of AT2 was unchanged (Figure 8BDown).



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Figure 8. A, Saturation binding of [125I]Ang II to neonatal rat cardiac myocyte membranes. Specific binding, as a function of increasing concentrations of [125I]Ang II, is shown. Ang II receptor densities were calculated by Scatchard analysis (inset). B, Mechanical stretch upregulates Ang II receptor densities in cardiac myocytes. Cardiac myocytes were stretched for 16 hours in the presence or absence of losartan (1 µmol/L) or PD123319 (1 µmol/L). No-Drug indicates stretch in the absence of any AT1- or AT2-specific antagonists; Losartan, pretreatment with losartan (1 µmol/L) for 30 minutes followed by stretch for 16 hours; and PD123319, pretreatment with PD123319 (1 µmol/L) for 30 minutes followed by stretch for 16 hours. Counts for total Ang II bound were normalized by the amount of membrane protein to obtain fmol/mg protein values. Data are mean±SEM of 5 separate experiments. A similar result was obtained by using cells enriched on a Percoll gradient.

Pretreatment of cells with losartan (1 µmol/L) for 30 minutes before stretch effectively reduced the increased density of the Ang II receptors to the values in the control cells (stretched myocytes, 69±7 fmol/mg protein; control myocytes, 72±3 fmol/mg protein). Reduced Ang II binding to stretched myocytes is not due to the remnant of losartan used for pretreatment, because we washed stretched myocytes extensively before we proceeded to the binding assay. These results indicate the effectiveness of AT1 antagonists in inhibiting mechanical stretch–induced increases in AT1 protein expression, which very closely correlates with the mRNA data on AT1A expression after mechanical stretch (Figure 8BUp).

Angiotensinogen, Renin, ACE, and AT1A Expression in Cardiac Fibroblasts Is Not Responsive to Stretching
We examined the possibility that a small (5% to 10%) contamination of fibroblasts in our myocyte-rich cultures could potentially contribute to the upregulation of renin-angiotensin system genes observed in stretched cardiac myocytes. To address this possibility, highly enriched cultures of cardiac nonmyocytes (mostly fibroblasts) were prepared by 2 passages of cells adhered to the culture dish during the preplating procedure.32 The cells were subsequently plated on the silicone substrate and then stretched for 0 to 24 hours. We have previously shown that mechanical stretch causes an increase in cell number in this fibroblast culture, which indicates that cardiac fibroblasts do respond to mechanical stretch.22 As shown in Figure 9Down, however, the relative expression of angiotensinogen, renin, ACE, and AT1A mRNA(s) in these fibroblast-rich cultures was not affected by stretching up to 24 hours (Figure 9Down, middle). Interestingly, treatment of fibroblast-rich cultures with Ang II also did not result in any appreciable changes in expression of angiotensinogen, renin, and ACE genes, but it caused a significant downregulation of AT1A expression (Figure 9Down, right). Receptor binding studies indicate that densities of both AT1 and AT2 in cardiac fibroblasts did not significantly change after stretch (data not shown).



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Figure 9. Effect of mechanical stretch and Ang II stimulation on renin-angiotensin system gene expression in cardiac fibroblasts in vitro. Cardiac fibroblast cultures were prepared as described. After a uniaxial stretch of 20% for 24 hours or Ang II (1x10–7 mol/L) (added every 8 hours) stimulation for 24 hours, cells were harvested to examine the expression of renin-angiotensin system genes by RT-PCR. The relative expression of various genes was obtained by densitometric analyses. Level of gene expression in unstretched or unstimulated myocytes was expressed as 1 arbitrary unit. Data are mean±SEM of 5 separate experiments.


*    Discussion
up arrowTop
up arrowAbstract
up arrowIntroduction
up arrowMaterials and Methods
up arrowResults
*Discussion
down arrowReferences
 
The present study demonstrates that mechanical loading of cultured cardiac myocytes leads to upregulation of angiotensinogen, renin, ACE, and AT1A genes. Stretch-induced increases in mRNA expression result in increased protein expression of the renin-angiotensin system in cardiac myocytes. Because our results were obtained by stretching cultured cardiac myocytes in vitro, stretch, but not systemic endocrine or neuronal mechanism, is the primary stimulus that activates intracellular signaling mechanisms leading to upregulation of renin angiotensin system genes.

Recently, it was reported that stretch-induced upregulation of AT1 and AT2 mRNAs was further enhanced by pretreatment with the AT1 antagonist CV11974 (10 µmol/L), which suggests that (secreted) Ang II actually downregulates expression of AT1.29 On the other hand, in our study, losartan (1 µmol/L) completely blocked stretch-induced upregulation of AT1 mRNA. The reasons for the different results between our study and that by Kijima et al29 are not clear at the present time. It is possible that CV11974 and losartan differentially affect cell signals mediated by AT1A. Although our results suggest that stimulation of AT1 is required for stretch-induced upregulation of AT1 mRNA, Ang II is unlikely to be the sole mediator of this response, given that Ang II alone downregulates expression of AT1. This may be explained if both stretch and Ang II are required for upregulation of AT1. Coordinated activation of multiple sets of second messengers by stretch and Ang II may be necessary for upregulation of AT1. Alternatively, a factor, or factors, with strong stimulatory effects on AT1 expression may be upregulated only in the presence of both stretch and Ang II.

The direct intracellular signaling mechanisms that couple the stimulus of mechanical stress to enhanced gene expression, in the present context of the renin-angiotensin system genes, are not yet deciphered. However, among the possible factors that may mediate the effect of mechanical stress is Ang II. In fact, in the present observations, exogenously applied Ang II upregulated the expression of the angiotensinogen, renin, and ACE genes, but downregulated the expression of the AT1A gene. In another study, Ang II modestly upregulated (<2-fold) the AT1A promoter activity in a transient transfection assay using cultured neonatal rat cardiac myocytes.33 One possible explanation for this conflicting observation is that the AT1A promoter used in the study is short and does not contain all of the cis-acting DNA elements required for its complete activity in cultured cardiac myocytes. The fact that both mechanical stretch and Ang II upregulated mRNA expression of angiotensinogen, renin, and ACE genes initially led us to hypothesize a common mechanism, ie, an Ang II–dependent mechanism. Unexpectedly, however, losartan completely inhibited Ang II–induced, but not mechanical stretch–induced, upregulation of angiotensinogen, renin, and ACE genes. Therefore, in addition to the secreted Ang II, mechanical stretch seems either to directly activate unique intracellular signaling molecules or to cause release of additional growth factors, which lead to an activation of the renin-angiotensin system genes. Cyclic mechanical stretch of cultured rat cardiac myocytes also upregulates angiotensinogen gene expression, an effect completely suppressed by pretreatment with losartan, which suggests an Ang II–dependent effect.34 Thus, it seems the type (uniaxial or cyclic) and degree of mechanical stretch may also influence the expression of renin-angiotensin system genes and their susceptibility to inhibition by Ang II receptor antagonists.

Recently, it has been demonstrated that several growth factors besides Ang II are secreted from the heart in response to mechanical stress. For example, stretch of neonatal rat cardiac myocytes causes secretion of endothelin-1.35 Release of basic fibroblast growth factor has also been demonstrated from adult rat ventricular myocytes in vitro in response to increased mechanical activity.36 Thus, it is possible that stretch of cells causes secretion of a number of still-undefined growth factors. The role of these autocrine/paracrine factors in stretch-induced upregulation of the cardiac renin-angiotensin system remains to be determined.

The observation that mechanical stretch and Ang II independently and differentially regulate the expression of cardiac renin-angiotensin system genes suggests both AT1-dependent and AT1-independent effects. The results seem to be in close agreement with recent observations documenting both Ang II–dependent and Ang II–independent effects on some intracellular signaling molecules. For instance, activation of the JAK/STAT (just another kinase/signal transducer and activator of transcription) pathway by acute pressure overload37 and that of the stress-activated protein kinases by mechanical stretch38 39 have both Ang II–dependent and Ang II–independent components. Kijima et al29 have reported that genistein-sensitive tyrosine kinases are involved in the Ang II–independent mechanisms, which mediate stretch-induced upregulation of AT1. This pathway is apparently not essential for stretch-induced upregulation of angiotensinogen, renin, and ACE (see Figure 7Up).

In the present report, we could not detect any expression of AT2 mRNA by RT-PCR in cardiac myocytes and cardiac fibroblasts. Our PCR conditions seem to be satisfactory, as a clear band was observed in a positive control sample (rat endothelial cell RNA). At the protein level, the AT2 binding site could be detected, albeit at low levels, by radioligand binding assay, but it did not show any response to mechanical stretching. This result on AT2 mRNA and protein expression is different from that reported by Kijima et al,29 who reported upregulation of AT2 mRNA in cultured neonatal rat cardiac myocytes after mechanical stretch. A potential explanation for the apparent lack of AT2 mRNA expression in our study is the difference in culture conditions, which may directly or indirectly affect the rate of synthesis and stability of AT2 mRNA and protein. The apparent PD123319-sensitive component of the Ang II receptor in our preparation may be encoded by a DNA sequence distinct from that of the known AT2. It is also pertinent to mention that Mukoyama et al40 and Kambayashi et al41 also could not detect any AT2 transcripts by Northern blot analyses using poly(A)+ RNA from rat hearts. AT2 appears to be abundantly expressed in fetal tissues and immature brain but present only at low levels in many adult tissues.42 43 Although Ang II has been shown to be sufficient to cause hypertrophic responses in neonatal rat cardiac myocytes in culture,12 32 some investigators have reported that Ang II has only weak hypertrophic effects in the same cell type.44 Because it has been reported that AT2 mediates antigrowth effects on cardiac myocytes,31 vascular smooth muscle cells,45 and endothelial cells,28 it is possible that differences in densities of AT2 may explain discrepancies of the hypertrophic effects of Ang II in different cardiac myocyte preparations among investigators.

Another interesting observation made in this investigation was that stretch upregulates the renin-angiotensin system only in cardiac myocyte cultures but not in cardiac fibroblast cultures. We have previously shown that in vitro stretch causes acute secretion of Ang II from cardiac myocyte cultures but not from cardiac fibroblast cultures.7 Thus, it is likely that some stretch-sensitive signaling mechanisms are missing in fibroblasts. It should be noted that our results do not exclude the role of cardiac fibroblasts in stretch-induced cell responses, because our myocyte cultures are not pure myocyte cultures. It is possible that both basal and stretch-induced secretion of "paracrine" factors from the "contaminating" cardiac fibroblasts may modulate stretch-induced cell responses in cardiac myocytes. A possible role of secreted endothelin-1 from cardiac nonmyocytes in modulating cardiac myocyte hypertrophy in culture has recently been demonstrated.46

In summary, our results suggest that stretch efficiently stimulates the renin-angiotensin system in cardiac myocytes. First, mechanical stress causes autocrine secretion of Ang II acutely. Subsequently, mechanical stress stimulates both mRNA and protein expression of the cardiac renin-angiotensin system through Ang II–independent mechanisms, thereby increasing cardiac (local) production of Ang II chronically. Cardiac production of Ang II not only directly causes hypertrophic effects but also stimulates mRNA expression of critical components of the renin-angiotensin system (although Ang II is dispensable for this response). The Ang II signal will be further amplified, because expression of AT1 is upregulated probably by unique coordinated effects of stretch and Ang II. Our results also indicate that Ang II–independent (genistein-insensitive) signaling mechanisms mediate stretch-induced upregulation of angiotensinogen, renin, and ACE, thereby mediating in part stretch-induced cardiac hypertrophy. Elucidation of precise signaling mechanisms that mediate stretch-induced upregulation of the renin-angiotensin system seems essential for better understanding of the mechanism of stretch-induced cardiac hypertrophy.


*    Acknowledgments
 
This study was supported by an NIH grant (to S.I.) and by a grant from American Heart Association Michigan (to J.S.). We thank Dr P. Saha for his help in radioligand binding assays.


*    Footnotes
 
This manuscript was sent to Leslie A. Leinwand, Consulting Editor, for review by expert referees, editorial decision, and final disposition.

Received November 3, 1998; accepted May 17, 1999.


*    References
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up arrowAbstract
up arrowIntroduction
up arrowMaterials and Methods
up arrowResults
up arrowDiscussion
*References
 
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Rapid electrical stimulation of contraction modulates gap junction protein in neonatal rat cultured cardiomyocytes: Involvement of mitogen-activated protein kinases and effects of angiotensin ii-receptor antagonist
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Am. J. Physiol. Regul. Integr. Comp. Physiol.Home page
M. Luodonpaa, H. Leskinen, M. Ilves, O. Vuolteenaho, and H. Ruskoaho
Adrenomedullin modulates hemodynamic and cardiac effects of angiotensin II in conscious rats
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Am. J. Physiol. Heart Circ. Physiol.Home page
J. Tan, H. Wang, and F. H. H. Leenen
Increases in brain and cardiac AT1 receptor and ACE densities after myocardial infarct in rats
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Am. J. Physiol. Heart Circ. Physiol.Home page
J. C. Borges, J. A. Silva Jr., M. A. Gomes, E. S. L. Lomez, K. M. Leite, R. C. Araujo, M. Bader, J. B. Pesquero, and J. L. Pesquero
Tonin in rat heart with experimental hypertrophy
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J. Physiol.Home page
N C Sundgren, G D Giraud, P J S Stork, J G Maylie, and K L Thornburg
Angiotensin II stimulates hyperplasia but not hypertrophy in immature ovine cardiomyocytes
J. Physiol., May 1, 2003; 548(3): 881 - 891.
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Am. J. Physiol. Heart Circ. Physiol.Home page
K. Shivakumar, D. E. Dostal, K. Boheler, K. M. Baker, and E. G. Lakatta
Differential response of cardiac fibroblasts from young adult and senescent rats to ANG II
Am J Physiol Heart Circ Physiol, April 1, 2003; 284(4): H1454 - H1459.
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J Am Coll CardiolHome page
M. A. East, J. G. Jollis, C. L. Nelson, D. Marks, and E. D. Peterson
The influence of left ventricular hypertrophyon survival in patients with coronaryartery disease: do race and gender matter?
J. Am. Coll. Cardiol., March 19, 2003; 41(6): 949 - 954.
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Circ. Res.Home page
M. A. Sussman, A. McCulloch, and T. K. Borg
Dance Band on the Titanic: Biomechanical Signaling in Cardiac Hypertrophy
Circ. Res., November 15, 2002; 91(10): 888 - 898.
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HypertensionHome page
K. Nagata, F. Somura, K. Obata, M. Odashima, H. Izawa, S. Ichihara, T. Nagasaka, M. Iwase, Y. Yamada, N. Nakashima, et al.
AT1 Receptor Blockade Reduces Cardiac Calcineurin Activity in Hypertensive Rats
Hypertension, August 1, 2002; 40(2): 168 - 174.
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HypertensionHome page
T. Nishikimi, Y. Mori, N. Kobayashi, K. Tadokoro, X. Wang, K. Akimoto, F. Yoshihara, K. Kangawa, and H. Matsuoka
Renoprotective Effect of Chronic Adrenomedullin Infusion in Dahl Salt-Sensitive Rats
Hypertension, June 1, 2002; 39(6): 1077 - 1082.
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Circ. Res.Home page
R. C. Pimentel, K. A. Yamada, A. G. Kleber, and J. E. Saffitz
Autocrine Regulation of Myocyte Cx43 Expression by VEGF
Circ. Res., April 5, 2002; 90(6): 671 - 677.
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Am. J. Physiol. Heart Circ. Physiol.Home page
D. Schultz, X. Su, C.-C. Wei, S. P. Bishop, P. Powell, G. H. Hankes, A. R. Dillon, P. Rynders, F. G. Spinale, G. Walcott, et al.
Downregulation of ANG II receptor is associated with compensated pressure-overload hypertrophy in the young dog
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L. Barlucchi, A. Leri, D. E. Dostal, F. Fiordaliso, H. Tada, T. H. Hintze, J. Kajstura, B. Nadal-Ginard, and P. Anversa
Canine Ventricular Myocytes Possess a Renin-Angiotensin System That Is Upregulated With Heart Failure
Circ. Res., February 16, 2001; 88(3): 298 - 304.
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J Am Coll CardiolHome page
Y. Sakata, T. Masuyama, K. Yamamoto, R. Doi, T. Mano, T. Kuzuya, T. Miwa, H. Takeda, and M. Hori
Renin angiotensin system-dependent hypertrophy as a contributor to heart failure in hypertensive rats: different characteristics from renin angiotensin system-independent hypertrophy
J. Am. Coll. Cardiol., January 1, 2001; 37(1): 293 - 299.
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Am. J. Physiol. Heart Circ. Physiol.Home page
P. A. Modesti, S. Vanni, I. Bertolozzi, I. Cecioni, G. Polidori, R. Paniccia, B. Bandinelli, A. Perna, P. Liguori, M. Boddi, et al.
Early sequence of cardiac adaptations and growth factor formation in pressure- and volume-overload hypertrophy
Am J Physiol Heart Circ Physiol, September 1, 2000; 279(3): H976 - H985.
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Cardiovasc ResHome page
K. Yamamoto, T. Masuyama, Y. Sakata, T. Mano, N. Nishikawa, H. Kondo, N. Akehi, T. Kuzuya, T. Miwa, and M. Hori
Roles of renin-angiotensin and endothelin systems in development of diastolic heart failure in hypertensive hearts
Cardiovasc Res, August 1, 2000; 47(2): 274 - 283.
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Cardiovasc ResHome page
D. MacKenna, S. R. Summerour, and F. J. Villarreal
Role of mechanical factors in modulating cardiac fibroblast function and extracellular matrix synthesis
Cardiovasc Res, May 1, 2000; 46(2): 257 - 263.
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H. Senzaki, N. Paolocci, Y. A. Gluzband, M. L. Lindsey, J. S. Janicki, M. T. Crow, and D. A. Kass
{beta}-Blockade Prevents Sustained Metalloproteinase Activation and Diastolic Stiffening Induced by Angiotensin II Combined With Evolving Cardiac Dysfunction
Circ. Res., April 14, 2000; 86(7): 807 - 815.
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Cardiovasc ResHome page
E. Cerbai, A. Crucitti, L. Sartiani, P. De Paoli, R. Pino, M. L. Rodriguez, G. Gensini, and A. Mugelli
Long-term treatment of spontaneously hypertensive rats with losartan and electrophysiological remodeling of cardiac myocytes
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J. Biol. Chem.Home page
C. Morisco, K. Seta, S. E. Hardt, Y. Lee, S. F. Vatner, and J. Sadoshima
Glycogen Synthase Kinase 3beta Regulates GATA4 in Cardiac Myocytes
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Circ. Res.Home page
G. G. N. Serneri, M. Boddi, I. Cecioni, S. Vanni, M. Coppo, M. L. Papa, B. Bandinelli, I. Bertolozzi, G. Polidori, T. Toscano, et al.
Cardiac Angiotensin II Formation in the Clinical Course of Heart Failure and Its Relationship With Left Ventricular Function
Circ. Res., May 11, 2001; 88(9): 961 - 968.
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Circ. Res.Home page
R. C. Pimentel, K. A. Yamada, A. G. Kleber, and J. E. Saffitz
Autocrine Regulation of Myocyte Cx43 Expression by VEGF
Circ. Res., April 5, 2002; 90(6): 671 - 677.
[Abstract] [Full Text] [PDF]


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