A Multifunctional Therapeutic Strategy Using P7C3 as A Countermeasure Against Bone Loss and Fragility in An Ovariectomized Rat Model of Postmenopausal Osteoporosis
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Fei Wei↗
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Pharmacokinetics and Pharmacodynamics in Space
The Pharmacokinetics and Pharmacodynamics Panel met on 29-30 Aug. 1988 at the Lunar and Planetary Institute in Houston, Texas to discuss pharmacokinetic and pharmacodynamic implications of space flight and make recommendations for operational and research strategies. Based on the knowledge available on the physiological changes that occur during space flight, the dependence of pharmacokinetics on physiological factors, and the therapeutic requirements for future space missions, the panel made several recommendations for research. It was suggested that using medications available with a large (wide) therapeutic window will avoid unforeseen therapeutic consequences during flight. The sequence for conducting research was outlined as follows: (1) identify ground-based simulation models (e.g., antiorthostatic bed rest) for conducting pharmacokinetic and pharmacodynamic research; (2) estimate parametric changes in these models using pharmacologic agents that have different pharmacokinetic characteristics and a narrow therapeutic index; (3) verify these findings during flight; and (4) develop and identify appropriate and effective drug delivery systems, dosage forms, and regimens. The panel recommended gaining a thorough understanding of the pharmacokinetic deviations of medications that have a narrow therapeutic index (e.g. cardiovascular drugs and sedative hypnotics) in order to ensure safe and effective treatment during flight with these agents. It was also suggested that basic information on physiological factors such as organ blood flow, protein composition and binding, tissue distribution, and metabolism by hepatic enzymes must be accumulated by conducting ground-based animal and human studies using models of weightlessness. This information will be useful to construct and identify physiologically based pharmacokinetic models that can provide valuable information on the pharmacodynamic consequences of space flight and aid in identifying appropriate therapeutic regimens.
Putcha, Lakshmi↗
Atrial Fibrillation During an Exploration Class Mission
Background: A long-duration exploration class mission is fraught with numerous medical contingency plans. Herein, we explore the challenges of symptomatic atrial fibrillation (AF) occurring during an exploration class mission. The actions and resources required to ameliorate the situation, including the availability of appropriate pharmaceuticals, monitoring devices, treatment modalities, and communication protocols will be investigated. Challenges of Atrial Fibrillation during an Exploration Mission: Numerous etiologies are responsible for the initiation of AF. On Earth, we have the time and medical resources to evaluate and determine the causative situation for most cases of AF and initiate therapy accordingly. During a long-duration exploration class mission resources will be severely restricted. How is one to determine if new onset AF is due to recent myocardial infarction, pulmonary embolism, fluid overload, thyrotoxicosis, cardiac structural abnormalities, or CO poisoning? Which pharmaceutical therapy should be initiated and what potential side effects can be expected? Should anti-coagulation therapy be initiated? How would one monitor the therapeutic treatment of AF in microgravity? What training would medical officers require, and which communication strategies should be developed to enable the best, safest therapeutic options for treatment of AF during a long-duration exploration class mission? Summary: These questions will be investigated with expert opinion on disease elucidation, efficient pharmacology, therapeutic monitoring, telecommunication strategies, and mission cost parameters with emphasis on atrial fibrillation being just one illustration of the tremendous challenges that face a long-duration exploration mission. The limited crew training time, medical hardware, and drugs manifested to deal with such an event predicate that aggressive primary and secondary prevention strategies be developed to protect a multibillion-dollar asset like the International Space Station or a mission to the Moon or Mars. Learning Objectives: The audience will become familiar with the risks and challenges inherent to developing a therapeutic strategy for the treatment of atrial fibrillation during a long-term exploration class mission.
Lipset, Mark A.↗
Human Spaceflight Applications of Novel Miniature X-Ray Technologies
INTRODUCTION: Radiography (XR) has long been a cornerstone of terrestrial medical imaging, though it has not yet been used in the spaceflight environment. Medical systems for human spaceflight missions are constrained by mass, volume, and power, and until recently, XR systems have been considered too large and power-consuming for spaceflight diagnostic and therapeutic applications. However, the rise of commercial spaceflight and NASA’s refocused efforts on returning crews to the Moon for long-duration missions have introduced a higher degree of medical risk to human spaceflight and require a re-evaluation when optimizing medical system design. Over the last decade, XR devices have miniaturized while maintaining good diagnostic and therapeutic sensitivity and specificity, making new in-flight medical and non-medical XR applications a possibility. Initial research identified several medical conditions where miniature XR would be beneficial for the diagnosis and/or management of medical conditions arising in space, though a more in-depth analysis is required to identify whether XR may add value to the management of such conditions. With this presentation, we aim to introduce the potential utility of miniature XR, review prior work highlighting where XR may be beneficial, and evaluate how miniature XR may reduce medical risk in human spaceflight missions. METHODS: IMPACT (Informing Mission Planning via Analysis of Complex Tradespaces) is a risk assessment tool developed by NASA to advance exploration mission medical system design by quantitatively estimating mission medical risk. IMPACT v1.0 includes a novel evidence library baselined to exploration environments, an expanded list of 119 medical conditions, medical capabilities and resources critical for management of these medical conditions, and the ability for rapid and iterative analysis in the setting of modifiable design reference missions (DRMs). Our first analysis identified which of the 119 medical conditions XR had diagnostic or therapeutic utility for. Subject matter experts (SMEs) recorded which XR views would be performed under ideal terrestrial circumstances for diagnosis/management of each condition, as well as which views are pragmatic for spaceflight limitations. A second analysis utilized IMPACT to identify significant conditions that contribute greatest to medical risk during a notional long-duration Lunar orbit and Lunar surface DRM. Medical system risk estimates include loss of crew life (LOCL), need for return to definitive care (RTDC; medical evacuation), and an estimate of crew task time affected (TTA). Using a standardized semi-quantitative scoring methodology, a deeper evaluation of each of the most significant medical conditions was performed. Data from both of these separate analyses were used to hypothesize what ideal and pragmatic XR studies may impact clinical management of the most significant conditions predicted to lead to medical risk. RESULTS: Approximately 1/3 of the IMPACT conditions were identified as being more effectively or comprehensively assessed or treated with the addition of miniature XR technology. The resulting conditions benefitting diagnostically and therapeutically from XR are revealed, as well as the ideal and pragmatic XR views and medical procedures benefitting from XR. The conditions of clinical significance and those most contributing to risk are also displayed. Among the conditions that contribute greatest to LOCL, four conditions for which XR may improve the diagnosis and management of include: decompression sickness, traumatic shock, dental abscess, and respiratory failure. Among conditions that contributed to RTDC, the evaluation and management of wrist fracture is likely improved by XR. For conditions leading to crew TTA, evaluation and management of EVA shoulder injuries, upper and lower extremity strains, back strains, and EVA hand injuries are likely improved by XR. DISCUSSION: Miniature XR in spaceflight has the potential to improve the evaluation and management of a substantial portion of conditions that most contribute to medical risk. This presentation is an introduction to the possibilities miniature XR provides for future human spaceflight missions and subsequent presenters will expand on potential applications in more detail. LEARNING OBJECTIVES: 1) Understand the previous limitations of using radiography in the management of spaceflight medical conditions; 2) Evaluate the findings from the IMPACT tool analysis, which allows quantification of the benefit miniature XR could provide for managing high-risk medical conditions in long-duration lunar orbit and surface missions, focusing on improvements in crew health outcomes; 3) Analyze case studies where miniature XR technology could reduce the medical risks associated with spaceflight missions, specifically in diagnosing and managing conditions such as decompression sickness, traumatic shock, and EVA-related injuries.
A Anderson↗
Hyperthermia in the treatment of cancer: A review of the radiobiological basis
Temperatures in the range 41.5 C to 43.5 C tend to be more damaging to malignant than nonmalignant cells. Where local hyperthermia (41.5 C to 43.5 C) is combined with ionizing radiation, a significant therapeutic ratio may be realized. Total body hyperthermia, alone or combined with other therapeutic modalities, can provide palliation for some systemic malignancies but may not be as effective as local hyperthermia for treating local disease. The influence of hyperthermia on immune mechanisms and the risk of metastatic spread of potential tumor growth stimulation need further investigation. Among other questions needing elucidation before hyperthermia can be considered a standard treatment modality are the time-dose (for heating) relationships to produce an optimal therapeutic ratio and whether the late sequela of combined heat and ionizing radiation may result in an unacceptable risk of patient morbidity.
Baker, D. G.↗
Experimental motion sickness - Efficacy of transdermal scopolamine plus ephedrine
A double-blind, placebo-controlled study compared the efficacy of transdermal therapeutic system-scopolamine administered alone and combined with ephedrine sulfate given orally in doses of 12.5, 25, and 50 mg. Eight normal male students were exposed to stressful accelerations in a slow-rotation room after receiving 10 apparently identical treatments comprising the four drugs and six placebos. Efficacy of the drug was defined in terms of the placebo range and categorized as beneficial, inconsequential, or detrimental. None of the effects was detrimental. Overall beneficial effects were 60% for transdermal therapeutic system-scopolamine (plus placebo) and 57% for the three transdermal therapeutic system-scopolamine plus ephedrine combinations.
Graybiel, A.↗
Transmembrane transport of peptide type compounds: prospects for oral delivery
Synthesis and delivery of potential therapeutic peptides and peptidomimetic compounds has been the focus of intense research over the last 10 years. While it is widely recognized that numerous limitations apply to oral delivery of peptides, some of the limiting factors have been addressed and their mechanisms elucidated, which has lead to promising strategies. This article will briefly summarize the challenges, results and current approaches of oral peptide delivery and give some insight on future strategies. The barriers determining peptide bioavailability after oral administration are intestinal membrane permability, size limitations, intestinal and hepatic metabolism and in some cases solubility limitations. Poor membrane permeabilities of hydrophilic peptides might be overcome by structurally modifying the compounds, thus increasing their membrane partition characteristics and/or their affinity to carrier proteins. Another approach is the site-specific delivery of the peptide to the most permeable parts of the intestine. The current view on size limitation for oral drug delivery has neglected partition considerations. Recent studies suggest that compounds with a molecular weight up to 4000 might be significantly absorbed, assuming appropriate partition behavior and stability. Metabolism, probably the most significant factor in the absorption fate of peptides, might be controlled by coadministration of competitive enzyme inhibitors, structural modifications and administration of the compound as a well absorbed prodrug that is converted into the therapeutically active agent after its absorption. For some peptides poor solubility might present a limitation to oral absorption, an issue that has been addressed by mechanistically defining and therefore improving formulation parameters. Effective oral peptide delivery requires further development in understanding these complex mechanisms in order to maximize the therapeutic potential of this class of compounds.
NASA Discipline Regulatory Physiology↗
Nanochanneled Device and Related Methods
A nanochannel delivery device and method of manufacturing and use. The nanochannel delivery device comprises an inlet, an outlet, and a nanochannel. The nanochannel may be oriented parallel to the primary plane of the nanochannel delivery device. The inlet and outlet may be in direct fluid communication with the nanochannel. Considerable advances have been made in the field oftherapeutic agent (e.g. drug) delivery technology over thelast three decades, resulting in many breakthroughs in clinicalmedicine. The creation of therapeutic agent deliverydevices that are capable of delivering therapeutic agents incontrolled ways is still a challenge. One of the majorrequirements for an implantable drug delivery device iscontrolled release of therapeutic agents, ranging from smalldrug molecules to larger biological molecules. It is particularlydesirable to achieve a continuous passive drug releaseprofile consistent with zero order kinetics whereby theconcentration of drug in the bloodstream remains constantthroughout an extended delivery period.These devices have the potential to improve therapeuticefficacy, diminish potentially life-threatening side effects,improve patient compliance, minimize the intervention ofhealthcare personnel, reduce the duration of hospital stays,and decrease the diversion of regulated drugs to abusiveuses.Nanochannel delivery devices may be used in drug deliveryproducts for the effective administration of drugs. Inaddition, nanochannel delivery devices can be used in otherapplications where controlled release of a substance overtime is needed. Embodiments of this invention comprise a nanochanneldelivery device having nanochannels within a structureconfigured to yield high mechanical strength and high flowrates. Various fabrication protocols may be used to form thenanochannel delivery device. Embodiments of the fabricateddevices feature horizontal nanochannel lay-out (e.g., thenanochannel is parallel to the primary plane of the device),high molecule transport rate, high mechanical strength,optional multilayered lay-out, amenability to select channellining materials, and possible transparent top cover. Basedon silicon microfabrication technology, the dimensions ofthe nanochannel area as well as concomitant microchannelareas can be precisely controlled, thus providing a predictable,reliable, constant release rate of drug (or other) moleculesover an extended time period. In certain embodiments,the nanochannel delivery device can be used to builda multilayered nanochannel structure.
Ferrari, Mauro↗
Antimotion-sickness efficacy of scopolamine 12 and 72 hours after transdermal administration
The antimotion sickness remedy, transdermal therapeutic system-scopolamine, administered in this experiment was scheduled to deliver 1.0 mg of scopolamine over a period of 3 d, and this paper compares its efficacy 12 and 72 h after administration. In a double-blind study, six male college students were individually exposed to a standardized provocative test in a slow rotation room after six apparently identical treatments comprising four placebos and two medications. Efficacy was categorized as beneficial, inconsequential, or detrimental. None of the responses was detrimental. Following the first administration of the therapeutic system, there were four beneficial responses after 12 h but none was beneficial after 72 h. Following the second treatment regimen, there were four beneficial responses after 12 h and three beneficial responses after 72 h. Great individual differences were demonstrated, two subjects accounting for six beneficial responses and two accounting for only one beneficial response. The difference in efficacy after 12 and 72 h has practical and theoretical significance.
Graybiel, A.↗
Mechanisms underlying the antimotion sickness effects of psychostimulants
Data related to the mechanism responsible for the antimotion sickness effects of psychostimulants such as amphetamine are examined. From the analysis of current literature and new evidence, the following three hypotheses are suggested: (1) selective enhancement of dopaminergic, but not noradrenergic, transmission is sufficient to account for amphetamine-induced resistance and, perhaps, for natural resistance to motion sickness; (2) the site of this enhanced dopaminergic transmission is probably within the basal ganglia; and (3) the neuropharmacology of the basal ganglia, but not of the brain-stem vestibular areas, can account for the therapeutic synergism of scopolamine and amphetamine. The therapeutic action of psychostimulants may be dissociable from some of their side effects, particularly cardiovascular effects related to peripheral norepinephrine release.
Kohl, Randall L.↗
Designing a training tool for imaging mental models
The training process can be conceptualized as the student acquiring an evolutionary sequence of classification-problem solving mental models. For example a physician learns (1) classification systems for patient symptoms, diagnostic procedures, diseases, and therapeutic interventions and (2) interrelationships among these classifications (e.g., how to use diagnostic procedures to collect data about a patient's symptoms in order to identify the disease so that therapeutic measures can be taken. This project developed functional specifications for a computer-based tool, Mental Link, that allows the evaluative imaging of such mental models. The fundamental design approach underlying this representational medium is traversal of virtual cognition space. Typically intangible cognitive entities and links among them are visible as a three-dimensional web that represents a knowledge structure. The tool has a high degree of flexibility and customizability to allow extension to other types of uses, such a front-end to an intelligent tutoring system, knowledge base, hypermedia system, or semantic network.
Dede, Christopher J.↗
Measurement and modification of the EEG and related behavior
Electrophysiological changes in the sensorimotor pathways were found to accompany the effect of rhythmic EEG patterns in the sensorimotor cortex. Additionally, several striking behavioral changes were seen, including in particular an enhancement of sleep and an elevation of seizure threshold to epileptogenic agents. This raised the possibility that human seizure disorders might be influenced therapeutically by similar training. Our objective in human EEG feedback training became not only the facilitation of normal rhythmic patterns, but also the suppression of abnormal activity, thus requiring complex contingencies directed to the normalization of the sensorimotor EEG. To achieve this, a multicomponent frequency analysis was developed to extract and separate normal and abnormal elements of the EEG signal. Each of these elements was transduced to a specific component of a visual display system, and these were combined through logic circuits to present the subject with a symbolic display. Variable criteria provided for the gradual shaping of EEG elements towards the desired normal pattern. Some 50-70% of patients with poorly controlled seizure disorders experienced therapeutic benefits from this approach in our laboratory, and subsequently in many others. A more recent application of this approach to the modification of human brain function in our lab has been directed to the dichotomous problems of task overload and underload in the contemporary aviation environment. At least 70% of all aviation accidents have been attributed to the impact of these kinds of problems on crew performance. The use of EEG in this context has required many technical innovations and the application of the latest advances in EEG signal analysis. Our first goal has been the identification of relevant EEG characteristics. Additionally, we have developed a portable recording and analysis system for application in this context. Findings from laboratory and in-flight studies suggest that we will be able to detect appropriate changes in brain function, and feed this information to on-board computers for modification of mission requirements and/or crew status.
Sterman, M. B.↗
Tissue Engineered Skeletal Myofibers can Directly "Sense" Gravitational Force Changes
Long-term manned space flight requires a better understanding of skeletal muscle atrophy resulting from microgravity. Atrophy most likely results from changes at both the systemic level (e.g. decreased circulating growth hormone, increased circulating glucocorticoids) and locally (e.g. decreased myofiber resting tension). Differentiated skeletal myofibers in tissue culture have provided a model system over the last decade for gaining a better understanding of the interactions of exogenous growth factors, endogenous growth factors, and muscle fiber tension in regulating protein turnover rates and muscle cell growth. Tissue engineering these cells into three dimensional bioartificial muscle (BAM) constructs has allowed us to extend their use to Space flight studies for the potential future development of countermeasures. Embryonic avian muscle cells were isolated and BAMs tissue engineered as described previously. The myoblasts proliferate and fuse into aligned postmitotic myofibers after ten to fourteen days in vitro. A cylindrical muscle-like structure containing several thousand myofibers is formed which is approximately 30 mm in length, 2-3 mm in diameter, and attached at each end. For the Space Shuttle experiments, the BAMs were transferred to 55 mL bioreactor cartridges (6 BAMs/cartridge). At Kennedy Space Center, the cartridges were mounted in two Space Tissue Loss (STL) Modules (three to four cartridges per Module) and either maintained as ground controls or loaded in a Mid-Deck locker of the Space Shuttle. The BAM cartridges were continuously perfused during the experiment at 1.5 mL/ min with tissue culture medium. Eighteen BAMs were flown for nine days on Mission STS66 while eighteen BAMs served as ground controls. The complete experiment was repeated on Mission STS77 with twenty four BAMs in each group. BAMs could be maintained in a healthy state for at least 30 days in the perfusion bioreactor cartridges. The BAM muscle fibers directly detected both the loss of gravity and the reloading effects of 1 x g. While total cellular metabolism and total protein degradation rates were not altered during 9 to 10 days in Space, protein synthesis rates were significantly reduced and resulted in significant myofiber atrophy compared to ground controls. One g reloading of the flight muscle cells post-flight significantly increased protein synthesis rates and the synthesis rates of myosin heavy chain, fibronectin, and collagen. Tissue cultured muscle cells can directly "sense" changes in gravity and provide a valid model to begin the study of countermeasures. Based on our ground based experiments, and the experiments of others, growth hormone and/or insulin-like growth factors are attractive protein therapeutics which may assisting attenuating skeletal muscle wasting in space. Our laboratory is developing a new cell-based delivery system for this and other potential therapeutic factors for attenuating muscle and bone wasting.
Vandenburgh, Herman H.↗
Bioavailability and Pharmacodynamics of Promethazine in Human Subjects
Space Motion Sickness (SMS) is often treated in space with promethazine (PMZ). Anecdotal reports indicate that the common side effects of drowsiness and decrements in cognitive performance that are associated with PMZ administration (50 mg IM on the ground, are absent or less pronounced in space suggesting I that-the bioavailability and/or pharmacodynamic behavior of PMZ may be altered during space flight. There are limited flight opportunities available for clinical research in space, the NRA-99, therefore, solicits research required to improve, or answer specific questions about in-flight diagnosis, therapy, and post-flight rehabilitation. We propose here, to establish a noninvasive method for pharmacodynamic and therapeutic assessment of PMZ. The specific objectives of the proposed research are to, 1. Establish a saliva to plasma ratio of PMZ after administration, 2. Estimate the relative bioavailability of the three flight-specific dosage forms of PMZ, and 3. Establish the dose-response relationship of PMZ. We will estimate the bioavailability of intramuscular injection (IM), oral tablets and rectal suppositories in normal subjects during ambulatory and antiorthostatic; bed rest (ABR) conditions using novel stable isotope techniques. Drowsiness, cognitive performance and salivary flow rate will be measured as a function of circulating drug concentrations after administration of three IM doses of PMZ. We will compare and contrast the bioavailability of PMZ during normal and ABR conditions to examine whether or not ABR can simulate changes in drug, absorption and availability similar to those anticipated in a microgravity environment. Results of this study will validate methods for an approved study with this medication awaiting a flight opportunity for manifestation. These data will also provide the much needed information on the dynamics and therapeutic index. of this medication and their implications on crew fatigue and performance in space. Key words: Promethazine, stable isotopes, bioavailability, pharmacodynamics, cognitive performance, antiorthostatic bed rest.
Putcha, Lakshmi↗
Detailed Test Objectives (DTOs) and Detailed Supplementary Objectives (DSOs)
The purpose of this experiment is to demonstrate the performance and operations of the GPS during orbiter ascent, entry and landing phases utilizing a modified military GPS receiver processor and the existing orbiter GPS antennas. The purpose of this experiment is to demonstrate the capability to perform a manually controlled landing in the presence of a crosswind. Changes in gastrointestinal function and physiology as a result of spaceflight affect drug absorption and the bioavailability of oral medications, which can compromise therapeutic effectiveness. This DSO will lead to the design and development of effective pharmocological countermeasures and therapeutic adjustments for spaceflight. A previous observation suggested that discordant sensory stimuli caused by an unusual motion environment disrupted spatial orientation and balance control in a returning crewmember by triggering a state change in central vestibular processing. The findings of the current investigation are expected to demonstrate the degree to which challenging motion environments may affect post-flight (re)adaptation to gravity.
Source record↗
Effect of stromal-cell-derived factor 1 on stem-cell homing and tissue regeneration in ischaemic cardiomyopathy
BACKGROUND: Myocardial regeneration via stem-cell mobilisation at the time of myocardial infarction is known to occur, although the mechanism for stem-cell homing to infarcted tissue subsequently and whether this approach can be used for treatment of ischaemic cardiomyopathy are unknown. We investigated these issues in a Lewis rat model (ligation of the left anterior descending artery) of ischaemic cardiomyopathy. METHODS: We studied the effects of stem-cell mobilisation by use of granulocyte colony-stimulating factor (filgrastim) with or without transplantation of syngeneic cells. Shortening fraction and myocardial strain by tissue doppler imaging were quantified by echocardiography. FINDINGS: Stem-cell mobilisation with filgrastim alone did not lead to engraftment of bone-marrow-derived cells. Stromal-cell-derived factor 1 (SDF-1), required for stem-cell homing to bone marrow, was upregulated immediately after myocardial infarction and downregulated within 7 days. 8 weeks after myocardial infarction, transplantation into the peri-infarct zone of syngeneic cardiac fibroblasts stably transfected to express SDF-1 induced homing of CD117-positive stem cells to injured myocardium after filgrastim administration (control vs SDF-1-expressing cardiac fibroblasts mean 7.2 [SD 3.4] vs 33.2 [6.0] cells/mm2, n=4 per group, p<0.02) resulting in greater left-ventricular mass (1.24 [0.29] vs 1.57 [0.27] g) and better cardiac function (shortening fraction 9.2 [4.9] vs 17.2 [4.2]%, n=8 per group, p<0.05). INTERPRETATION: These findings show that SDF-1 is sufficient to induce therapeutic stem-cell homing to injured myocardium and suggest a strategy for directed stem-cell engraftment into injured tissues. Our findings also indicate that therapeutic strategies focused on stem-cell mobilisation for regeneration of myocardial tissue must be initiated within days of myocardial infarction unless signalling for stem-cell homing is re-established.
NASA Discipline Cardiopulmonary↗
Pharmacokinetic consequences of spaceflight
Spaceflight induces a wide range of physiological and biochemical changes, including disruption of gastrointestinal (GI) function, fluid and electrolyte balance, circulatory dynamics, and organ blood flow, as well as hormonal and metabolic perturbations. Any of these changes can influence the pharmacokinetics and pharmacodynamics of in-flight medication. That spaceflight may alter bioavailability was proposed when drugs prescribed to alleviate space motion sickness (SMS) had little therapeutic effect. Characterization of the pharmacokinetic and/or pharmacodynamic behavior of operationally critical medications is crucial for their effective use in flight; as a first step, we sought to determine whether drugs administered in space actually reach the site of action at concentrations sufficient to elicit the therapeutic response.
NASA Center JSC↗
[Modifications in myocardial energy metabolism in diabetic patients]]
The capacity of cardiac myocyte to regulate ATP production to face any change in energy demand is a major determinant of cardiac function. Because FA is the main heart fuel (although the most expensive one in oxygen, and prompt to induce deleterious effects), this process is based on a balanced fatty acid (FA) metabolism. Several pathological situations are associated with an accumulation of FA or derivatives, or with an excessive b-oxidation. The diabetic cardiomyocyte is characterised by an over consumption of FA. The control of the FA/glucose balance clearly appears as a new strategy for cytoprotection, particularly in diabetes and requires a reduced FA contribution to ATP production. Cardiac myocytes can control FA mitochondrial entry, but display weak ability to control FA uptake, thus the fate of non beta-oxidized FA appear as a new impairment for the cell. Both the trigger and the regulation of cardiac contraction result from membrane activity, and the other major FA function in the myocardium is their role in membrane homeostasis, through the phospholipid synthesis and remodeling pathways. Sudden death, hypercatecholaminemia, diabetes and heart failure have been associated with an altered PUFA content in cardiac membranes. Experimental data suggest that the 2 metabolic pathways involved in membrane homeostasis may represent therapeutic targets for cytoprotection. The drugs that increase cardiac phospholipid turnover (trimetazidine, ranolazine,...) display anti-ischemic non hemodynamic effect. This effect is based on a redirection of FA utilization towards phospholipid synthesis, which decrease their availability for energy production. A nutritional approach gave also promising results. Besides its anti-arrhythmic effect, the dietary docosahexaenoic acid is able to reduce FA energy consumption and hence oxygen demand. The cardiac metabolic pathways involving FA should be considered as a whole, precariously balanced. The diabetic heart being characterised by a different metabolic "status" with similarities to that of myocardium in coronary disease. Diabetes and other chronic cardiac diseases share common FA metabolism disorders leading to an altered energy balance, a decrease in long chain polyunsaturated Fas, and altered FA profiles in cardiac membranes. These disturbances, however, do not represent independent therapeutic targets, and should be considered as a whole.
Myocardium/metabolism↗