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Journal of Physiology (2001), 533.1, pp. 253-261
© Copyright 2001 The Physiological Society
| ABSTRACT |
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| INTRODUCTION |
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Persistent patency of the DA is the second most common congenital heart defect in infancy and childhood (Coggin et al. 1970). Consequently, an understanding of the normal mechanism of closure is critically important. The DA acts as a right to left shunt in the developing fetus. At birth the rise in alveolar O2 tension initiates constriction of the DA, thus eliminating the shunt (Heymann & Rudolph, 1975). The incidence of patent DA is greater under hypoxic conditions, as in populations living at high altitude (Alzamora-Castro et al. 1960). While the mechanism by which O2 initiates constriction is through a direct effect on the DA smooth muscle cells (SMCs; Fay, 1971), the transduction pathway by which this change is signalled is unclear (Smith, 1998). There are substantial data suggesting that the release of endothelin (Coceani et al. 1989, 1992) and decreased levels of dilator prostaglandins (Coceani & Olley, 1973; Clyman et al. 1978) are likely to be important in maintaining DA closure, but the initiating mechanism remains controversial. Roulet & Coburn (1981) showed that the initial closure is, at least partially, dependent on changes in the membrane potential, since O2-dependent constriction could be significantly reduced by preconstriction with 126 mM KCl. Consistent with this, recent data demonstrate that increases in O2 tension can inhibit K+ channel activity recorded from DA SMCs, depolarize the membrane potential and increase intracellular Ca2+ (Nakanashi et al. 1993; Tristani-Firouzi et al. 1996). K+ channel inhibition may therefore be involved in normoxic constriction of the DA. We have previously suggested that redox changes provide the signal by which O2 alters the K+ channel gating in pulmonary artery SMCs (Archer et al. 1986, 1993; Reeve et al. 1995). Consequently, if the DA behaves in a similar manner to the lung, in terms of redox changes, an increase in O2 tension would be expected to increase O2 radical production (Freeman & Crapo, 1981). We investigated the redox mechanism by which DA SMC K+ channels might sense the change in O2 at birth. We determined that the H2O2 level does increase during normoxia in the DA tissue and that the removal of endogenous H2O2 by catalase increases IK. Oxidizing agents constrict isolated hypoxic DA rings, while reducing agents and agents that facilitate electron transfer dilate normoxic DA rings. These results suggest that the shift in the cytosolic redox status of DA SMCs to a more oxidized state, associated with increased H2O2, acts as the signalling mechanism for DA K+ channel inhibition and constriction at birth.
| METHODS |
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All animal studies were approved by the Institutional Animal Care and Use Committee, and conformed to current National Institutes of Health and American Physiological Society guidelines for the use and care of laboratory animals.
Determination of tissue levels of reactive O2 species
Rabbit DA rings were isolated from fetal pups as previously described (Tristani-Firouzi et al. 1996) and maintained at 37 oC in a Krebs-Hensleit bicarbonate-buffered solution. Rings were bubbled for 20 min with either 2.5 % O2-2.5 % CO2-balance N2 (hypoxia) or 20 % O2-2.5 % CO2-balance N2 (normoxia), and then incubated with either 50 µM luminol or 5 µM lucigenin for a further 15 min (continuous bubbling), before measuring chemiluminescence in a liquid scintillation counter (Packard 1900CA). In some experiments, chemiluminescence was measured in normoxic tissue prior to the 15 min incubation with 1200 U ml-1 catalase, after which chemiluminescence was measured again. At the time of chemiluminescence measurement, pH was 7.37 ± 0.01 (hypoxia) and 7.35 ± 0.01 (normoxia); temperature was 38.8 ± 0.2 oC (hypoxia) and 38.6 ± 0.2 oC (normoxia) and PO2 was 30.8 ± 1.8 mmHg (hypoxia) and 140 ± 5.9 mmHg (normoxia). Background counts (blanks) were recorded in luminol- or lucigenin-containing solutions in the absence of tissue and subtracted to obtain final counts. In these blanks, there was no significant difference in counts between normoxia and hypoxia. All counts were adjusted for total weight (mg). Numbers presented (n) indicate the actual number of DAs used which were harvested from fetuses from at least three different mother rabbits to allow for animal variation. The total number of mother rabbits used for the study was 46.
Electrophysiology
The conventional, whole-cell patch-clamp configuration (Hamill et al. 1981), was used to record K+ current and membrane potential from freshly isolated fetal DA SMCs. Cells were obtained as previously described by a two-step enzymatic digestion with papain and collagenase (Tristani-Firouzi et al. 1996). For normoxic recordings, cells were allowed to equilibrate with room air throughout the digestion and subsequent refrigeration in low Ca2+ Hanks' solution. For hypoxic recordings, all solutions were deoxygenated with N2. Recordings of both K+ current and membrane potential were made using an extracellular perfusate of composition (mM): NaCl, 115; KCl, 5.4; MgCl2, 1; NaHCO3, 25; CaCl2, 1.5; Hepes, 10 and glucose, 10 (pH 7.4 with NaOH). For hypoxic recordings, this solution was bubbled with 2.5 % CO2-balance N2 (bath PO2 = 36 ± 3.8 mmHg; n = 12) while for normoxic recordings, the solution was bubbled with 20 % O2-2.5 % CO2-balance N2 (bath PO2 = 125 ± 6.2 mmHg; n = 9). Cells were perfused at a rate of 2 ml min-1. Electrodes were pulled from borosilicate glass and had a resistance of 2.75-4.0 M
when filled with a solution of (mM): KCl, 140; MgCl2, 1; Hepes, 10; ATP, 1 and EGTA, 0.1 (pH 7.2 with KOH). For recording K+ current, both current-voltage (I-V) curves and ramp protocols were used. I-V curves were constructed by stepping from a holding potential of -70 mV using 100 ms duration pulses at a frequency of 0.1 Hz. Compensation of whole-cell capacitance allowed an estimation of cell size (10.2 ± 0.4 pF, n = 33) allowing I-V curves to be constructed using both current (pA) and current density (pA pF-1). Ramps of 1 s duration were recorded from the same holding potential. Currents were filtered at 1 kHz and digitized at 2 kHz. Membrane potential recordings were made using the whole-cell configuration with the same electrode solutions at the resting potential of the cell (without current injection). Series resistance and leak were checked at the beginning and end of each membrane potential experiment to eliminate artifactual changes in potential. All data were recorded and analysed using pCLAMP 6.04 software (Axon Instruments, Foster City, CA, USA). For recordings of the effect of catalase, 200 U ml-1 was included in the pipette solution and pH tested to eliminate potential pH-induced effects. To eliminate superoxide (O2-·) effects, 100 U ml-1 superoxide dismutase was included in the pipette. H2O2 (100 nM) was included in the pipette while t-butyl H2O2 (t-BOOH; 1 and 100 µM) and N-mercaptopropionylglycine (NMPG; 10 mM) were added directly to the bath via a microinjection pipette.
Measurement of changes in tone in isolated DA rings
Ductus arteriosus rings were equilibrated in Earle's bicarbonate buffered medium under hypoxia (0 % O2-2.5 % CO2-balance N2: PO2
30 mmHg) for 60 min at a tension of 400 mg. This tension has been proven to be optimal for this tissue as determined by previous studies using increasing concentrations of KCl. Three micromolar indomethacin and 100 µM L-NAME were present throughout all experiments. These inhibitors of prostaglandin and nitric oxide synthesis, respectively, were used so that a contractile mechanism independent of these mediators could be studied. Drugs were added to the bath in either hypoxia (DA dilated) or normoxia (DA constricted; 20 % O2-2.5 % CO2-balance N2: PO2 = 135 mmHg). Vehicle controls were done for all drugs used. Oxygen tension was recorded continuously using an M1-730 oxygen electrode (Microelectrode Inc., Bedford, NH, USA; tip diameter 2 mm). To determine potential O2-scavenging effects of NMPG and dithiothreitol (DTT), in vitro experiments were also done. For these experiments Earle's bicarbonate buffer was equilibrated in the organ baths with normoxic gas, as above, but no tissue was added. Increasing concentrations of DTT and NMPG (1, 5 and 10 mM) were then added to the bath and changes in O2 tension recorded.
Drugs
All drugs and salts were obtained from Sigma-Aldrich Chemicals Inc. (St Louis, MO, USA) except H2O2 (General Medical Corp. Richmond, VA, USA).
Statistical analysis
Values are expressed as means ± S.E.M. Student's unpaired and paired t tests were used to compare membrane potential recordings and DA changes in tone, respectively, while repeated measures or factorial ANOVAs were used to compare changes in IK and chemiluminescence. A value of P < 0.05 was considered significant.
| RESULTS |
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It has previously been shown that the cytosolic redox status shifts to a more oxidized state with an increase in O2 tension from hypoxia to normoxia (Freeman & Crapo, 1981), such as that which occurs in the DA at birth. To investigate changes in levels of reactive O2 species (ROS) in the DA, luminol- and lucigenin-enhanced chemiluminescence was recorded in isolated DA rings in either hypoxia or normoxia. Chemiluminescence was consistently higher in normoxic DA tissue than in hypoxic, using either luminol (758 ± 194 counts in hypoxia, 1178 ± 202 counts in normoxia; n = 23 ductuses) or lucigenin (386 ± 34 counts in hypoxia, 986 ± 82 counts in normoxia; n = 11 ductuses), and could be decreased on return to hypoxia (Fig. 1A). This technique, while not selective for specific radicals, has been shown to measure the superoxide dismutase-sensitive production of radicals and peroxides from the isolated lung surface (Archer et al. 1989). Incubation of the tissue with the enzyme catalase (1200 U ml-1), which specifically degrades H2O2, completely reversed the normoxic rise in chemiluminescence suggesting that this increase in chemiluminescence may be due to a concomitant rise in H2O2 levels (Fig. 1A). The normoxic rise in radical production was also reversed by the electron-shuttling agent duroquinone (100 µM; n = 28; Fig. 1B).
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Figure 1. Redox activity A, values (means ± S.E.M.) of luminol-enhanced chemiluminescence (CL) recorded from DA rings following equilibration in hypoxia (
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K+ currents recorded from normoxic DA SMCs were significantly decreased and membrane potentials were significantly depolarized as compared to hypoxic DA SMCs (Fig. 2). To determine whether modulation of endogenous H2O2 or O2-· levels in DA SMCs could affect K+ channel activity, 200 U ml-1 catalase or 100 U ml-1 superoxide dismutase was included in the patch pipette prior to recording K+ currents in normoxia. In catalase- treated cells, a time-dependent increase in K+ current was observed, with currents increasing at 8 min (46 ± 12 % increase from control at +50 mV; n = 6) and plateauing at 20 min (124 ± 12 % increase from control at +50 mV; n = 6; Fig. 3A and B). Control recordings with either no catalase (n = 6), 200 U ml-1 boiled catalase (n = 8), sodium citrate (catalase buffer; n = 5) or an equimolar concentration of albumin (protein control; n = 3) had no effect on IK over the same time (-0.1 ± 5 %; 1.2 ± 3 %; -2.5 ± 4 % and 1.6 ± 1 % changes from control at 20 min dialysis at +50 mV, respectively, and Fig. 3D). Following catalase, total normoxic whole-cell current was not significantly different from that recorded in hypoxia without catalase (Fig. 3D). Recordings of membrane potential with 200 U ml-1 catalase in the pipette showed a time-dependent membrane hyperpolarization, which would be consistent with the opening of K+ channels (Fig. 4A and C). The hyperpolarization began after approximately 4 min. This is a similar time course to the increase in IK that was recorded in voltage clamp with 200 U ml-1 catalase in the pipette (Fig. 3). No change in membrane potential was recorded from cells dialysed with boiled catalase (Fig. 4A and B). Bath application of the cell-permeable form of H2O2 (t-BOOH) caused partial, reversible inhibition of IK at 1 µM (Fig. 5A, n = 5; 13.3 ± 9 % inhibition at 2 min at +50 mV; n.s.) as did low concentrations of intracellular H2O2 (100 nM) given via the patch-pipette (n = 4, 13.2 ± 4 % decrease at +50 mV; data not shown). Increasing the concentration of t-BOOH to 100 µM caused almost complete suppression of IK with partial recovery occurring on washout (Fig. 5B; 77 ± 6.2 % decrease at +50 mV; n = 4). Recordings of membrane potential showed that 1 µM t-BOOH had no effect even up to 5 min application, while 100 µM rapidly and reversibly depolarized membrane potential from -29 ± 6.7 mV to -1.4 ± 2.1 mV (an average depolarization of 27.6 ± 4.5 mV; n = 3; P < 0.05; Fig. 5C). Including superoxide dismutase in the pipette had no significant effect on the K+ current recorded over the same time period as the catalase experiments (7.4 ± 11 % change in IK at +50 mV after 16 min dialysis, data not shown; n = 5).
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Figure 2. K+ channel activity and membrane potential A, representative actual current traces recorded from a DA smooth muscle cell in hypoxia (left) and following prolonged (1-3 h) normoxia (right). Cells were held at a membrane potential of -70 mV and stepped to +50 mV in +20 mV increments. B, values (means ± S.E.M.) of whole-cell K+ currents recorded from ductus arteriosus (DA) smooth muscle cells at +30 mV following prolonged exposure to hypoxia or normoxia. C, values (means ± S.E.M.) for membrane potential (Vm) recorded from cells under the same conditions as in A and B. Number of cells studied shown in parentheses. * P < 0.05.
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Figure 3. Catalase modulation of K+ current A, values (means ± S.E.M.) I-V relationship of current density (pA pF-1) recorded at 2 min (
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Figure 4. Catalase modulation of membrane potential A, values (means ± S.E.M.) values of membrane potential (Vm) recorded from control normoxic cells (
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Figure 5. H2O2 modulation of K+ current A and B, representative voltage ramps recorded over 1 s from -70 mV to +50 mV during hypoxia and following 1 min bath application of 1 µM t-butyl H2O2 (t-BOOH; A) or 100 µM t-BOOH (B). C, actual trace of membrane potential recorded during bath application of 100 µM t-BOOH and following wash. Time course of t-BOOH application indicated by bar.
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The electron-shuttling agent duroquinone had no effect on tone in hypoxic DA rings but consistently dilated normoxia-constricted rings (Fig. 6A; n = 6). The reducing agents DTT (1 mM; n = 4) and NMPG (10 mM; n = 8) also dilated normoxic rings (Fig. 6B and C, P < 0.01). Neither of these agents had any direct, scavenging effect on PO2 levels even at 10 mM (Fig. 7A). In patch-clamp experiments, NMPG (10 mM) also significantly increased IK (35 ± 7.8 % increase at +50 mV after 8 min, n = 4; P < 0.05; data not shown). In contrast to the reducing agents and electron shuttler, the oxidizing agent 5,5'-dithiobis-(2-nitrobenzoic acid) (DTNB; 1 mM) partially constricted hypoxic DA rings (n = 5; Fig. 7B). In the presence of DTNB, normoxia only constricted the DA rings to the levels achieved by normoxia in the absence of DTNB, suggesting the two mechanisms of constriction to be similar, not additive.
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Figure 6. Effects of reducing agents on tone A-C, representative recordings of DA tone after exposure to normoxia and following treatment with the electron-shuttling agent duroquinone (1, 10 and 100 µM; A); the reducing agent dithiothreitol (DTT; 1 mM; B) and the reducing agent and H2O2 scavenger N-mercaptopropionylglycine (NMPG; 10 and 30 mM; C). Drugs added as indicated by arrows. Bar indicates period of exposure to normoxia.
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Figure 7. Effects of oxidizing agents on tone A, in vitro recording of effects of NMPG and DTT on O2 levels (PO2) under conditions used for DA ring studies but without tissue present. Drugs added as indicated by arrows. B, values (means ± S.E.M.) of changes in DA tone (
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| DISCUSSION |
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The mechanism by which the DA constricts at birth remains controversial (for review see Smith, 1998). While it is widely accepted that dilator prostaglandins (in particular PGE2) are essential in maintaining patency of the ductus during development (Coceani & Olley, 1988) closure of the DA requires more than just the passive removal of this dilator effect. It has been suggested that the rise in O2 at birth releases endothelin from endothelial and smooth muscle cells and that this causes constriction of the DA via the ETA (endothelan A) receptor (Coceani et al. 1992). While it is possible that changes in endothelin levels maintain the closure of the DA in the neonate, there is evidence that this is not the mechanism by which initial DA constriction occurs (Fineman et al. 1998; Smith, 1998). This means that alternative pathways must be investigated. Roulet & Coburn (1981) found that O2-induced constriction of the DA was associated with smooth muscle depolarization, indicating a role for changes in ion channel activity in closure, in particular K+ channel activity which controls resting membrane potential in DA SMCs (Tristani-Firouzi et al. 1996).
While the O2 sensitivity of K+ channels is a generally accepted phenomenon (Lopez-Barneo et al. 1988; Peers, 1990; Post et al. 1992; Youngson et al. 1993; Archer et al. 1996; Buckler, 1997; Ospienko et al. 1997) the signalling mechanism by which the channels sense changes in O2 remains unknown. We report here a mechanism by which redox changes in the cytosol of SMCs may act as the sensor to trigger changes in K+ channel activity. Recent controversy has arisen regarding changes in ROS in hypoxia and normoxia. While it might seem intuitive that levels of ROS would decrease in hypoxia, and indeed this has been shown to be the case in some tissues (Freeman & Crapo, 1981; Archer et al. 1989), recent studies have also reported increased levels of ROS in hypoxia (Chandel et al. 1998; Duranteau et al. 1998; Killilea et al. 2000). The reason for these discrepancies is unknown but may relate to differences in technique for recording redox status (fluorescence assay versus chemiluminescence), differences between fresh tissue and cultured cells and exposures to hypoxia (short-term versus prolonged or ischaemia/reperfusion). Since none of the techniques routinely used for measuring redox status are considered completely specific, it might be wise to always use a combination of techniques for these measurements. For the studies presented, changes in the redox status of the cytosol were measured using chemiluminescence. Chemiluminescence has been criticized for its potential to indirectly produce O2-· in normoxia (Fridovich, 1997). To try to ensure that the change in ROS was not a result of auto-oxidation in normoxia, studies were carried out using both lucigenin and luminol, and similar results recorded. Furthermore, background counts, recorded prior to addition of tissue, did not change significantly between normoxia and hypoxia. Together, these experiments suggest that ROS levels increase in normoxia in the DA. In addition, the change in ROS recorded by switching from hypoxia to normoxia could be completely reversed by incubation of the tissue with the H2O2 metabolizing enzyme, catalase. Extracellular catalase has been previously shown to reduce increases in intracellular H2O2 as recorded by fluorescence techniques (Maziar Zafari et al. 1998). This suggests that the H2O2 is either freely diffusible or the catalase can enter the cell. The reversal of the increase in ROS by catalase indicates that the majority of the increase in chemiluminescence recorded was due to endogenous increases in levels of H2O2, or a subsequent ROS such as the hydroxyl radical (OH·).
There is substantial evidence that K+ channels are redox sensitive (Ruppersburg et al. 1991; Vega-Saenz de Miera et al. 1992; Park et al. 1997; Szabo et al. 1997; Filipovic & Reeves, 1997), including elegant studies showing that H2O2-sensitive channels have a common cysteine residue in a similar amino acid sequence at the amino (intracellular) terminus of the protein (Vega-Saenz de Miera et al. 1992). However, most previous studies have determined the effects of high concentrations of exogenous redox agents given via the extracellular perfusate. Since physiological changes in the redox status of the cell would primarily affect intracellular sites, this method of application is not optimal. Indeed, previous studies looking at the effects of H2O2 often used micromolar concentrations (Szabo et al. 1997; Filipovic & Reeves, 1997) which are a million times greater than concentrations that would be produced by the mitochondria (nM) (Phung et al. 1994), which in our hands could not be tolerated by vascular SMCs if given directly into the cytosol (H. L. Reeve, unpublished observations).
To determine the effect of endogenous H2O2 on K+ currrents in the DA SMCs, catalase was included in the pipette to enhance the breakdown of cellular H2O2 to O2 and H2O. As the pipette solution dialysed into the cell, it produced a significant increase in the amplitude of IK and membrane hyperpolarization. Since we also show that H2O2 and/or associated ROS levels increase in normoxia in DA, this observation is consistent with K+ channels being open, membrane potential being hyperpolarized and the DA being dilated under hypoxic conditions, when H2O2 levels are low. The formation of O2 from H2O2 through the action of catalase cannot be responsible for K+ channels being open, as an increase in O2 results in closure of K+ channels and membrane depolarization (Tristani-Firouzi et al. 1996). Since other ROS can be formed during normoxia including O2-· and OH·, studies were also done with superoxide dismutase in the pipette to investigate potential effects of endogenous O2 on K+ channels. There was no significant effect of superoxide dismutase on IK. Since superoxide dismutase will remove endogenous O2-· by the production of H2O2, it might be hypothesized that its presence in the pipette should actually cause a decrease in the amplitude of IK. In five cells in which this was monitored, there was no consistent decrease in IK over time. It is likely, therefore, that H2O2 produced by the metabolism of superoxide dismutase is removed by endogenous catalase activity and that there is no change in the absolute quantity of H2O2 generated. A potential role of OH· in the K+ channel effect of catalase should be considered. Theoretically, removal of H2O2 with catalase would lead to a decrease in levels of any OH· formed via the Haber-Weiss reaction and so the increase in IK observed with catalase could be related to reduced levels of OH·. Since the formation of OH· via the Haber-Weiss reaction also requires the presence of O2-·, it might be expected that if the decrease in OH· found with catalase were responsible for the increase in IK, this increase would also be observed in cells dialysed with superoxide dismutase. This was not the case, suggesting that it is a change in the level of endogenous H2O2 which is directly affecting the K+ channels.
While levels of endogenous H2O2 do appear to change between hypoxia and normoxia in the DA, the source of the changes has not been explored in this study. For instance, the increase in H2O2 in normoxia could result from an increase in cytosolic levels as a result of mitochondrial production or the activity of NADPH oxidase.
In addition to modulation of tone, changing K+ channel activity has also been shown to directly affect cellular proliferation (Chiu & Wilson, 1989; Nilius & Wohlrab, 1992; Vaur et al. 1998). Indeed a combination of the two effects are often intimately linked in pathophysiological events in the pulmonary circulation. In the DA, normoxic constriction is followed by cellular necrosis and fibrosis to obliterate the shunt pathway (Heymann & Rudolph, 1975; Drayton & Skidmore, 1987). Recent data show that H2O2 levels can also directly modulate cellular proliferation, as an over-expression of catalase in smooth muscle (and hence a removal of endogenous H2O2 equivalent to hypoxia) inhibits proliferation (Maziar Zafari et al. 1998; Brown et al. 1999). Whether this also occurs through changes in K+ channel activity is unknown but indicates an additional, important correlation between H2O2 levels and smooth muscle cellular physiology.
The reducing agent NMPG has been shown to scavenge H2O2 in PC12 cells and to reduce levels to those found in hypoxia (Czyzyk-Krzeska et al. 1998). In the DA, NMPG both increased IK and dilated normoxic-constricted rings. Consistent with these observations, other reducing or electron shuttling agents such as DTT and duroquinone, also dilated normoxia-constricted DA rings. Since duroquinone can act to shuttle electrons in either direction, studies were done to determine its effect on chemiluminescence in isolated rings. It was found to decrease chemiluminescence to levels similar to hypoxia (Fig. 1B) suggesting that it was, in fact, acting like a reducing agent. While the concentrations of these agents used to cause dilatation were higher than those found to affect IK, they appeared to have no direct O2-scavenging effects which could have explained their dilator properties (Fig. 7A). It is likely that the higher concentrations used in rings simply reflect the difference between giving a drug directly to the smooth muscle cells (as occurs in the patch-clamp experiments) and requiring it to enter the smooth muscle layer in a ring with intact endothelium and adventitia. Experiments in isolated hypoxic DA with the oxidizing agent DTNB show that there is no significant difference between the nomoxia-induced constriction and the DTNB constriction. In addition, exposure of DTNB-constricted rings to normoxia, in the continued presence of the oxidizing agent, causes no additional change in tone. This suggests that the mechanism by which oxygen constricts the DA is redox dependent.
The DA and pulmonary arteries have exactly opposite responses to O2. Consequently it is not surprising that in the pulmonary artery and in isolated lungs, reducing agents cause vasoconstriction (Reeve et al. 1995). Similarly, oxidizing agents are known to dilate the pulmonary vasculature (Reeve et al. 1995) while in the DA they cause constriction. Pulmonary arteries constrict in response to hypoxia through inhibition of a Kv channel, (Yuan et al. 1993; Archer et al. 1996) while the rabbit DA may initially constrict in response to normoxia through inhibition of a Kv channel (Tristani-Firouzi et al. 1996). The data presented give rise to the intriguing concept that the same cytosolic redox changes in these two tissues have opposite effects on K+ channel gating, accounting for their opposing responses to O2.
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Acknowledgements
H.L.R. is supported by NIH award R29 HL59182-01. E.K.W. is supported through funding from the Veterans Affairs Merit Review, NIH award ROI HL65322-01 and the American Heart Association. S.L.A. is supported by MRC Canada, the Alberta Heart and Stroke Foundation and The Heritage Foundation.
Corresponding author
E. K. Weir: Cardiology IIIc, VA Medical Center, Minneapolis, MN 55417, USA.
Email: weirx002{at}maroon.tc.umn.ed
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