Consequences of Brief Ischemia: Stunning, Preconditioning, and Their Clinical

Implications : Part 2
Robert A. Kloner and Robert B. Jennings
Circulation 2001, 104:3158-3167
doi: 10.1161/hc5001.100039
Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514
Copyright 2001 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online
ISSN: 1524-4539

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Clinical Cardiology: New Frontiers

Consequences of Brief Ischemia: Stunning, Preconditioning,
and Their Clinical Implications
Part 2
Robert A. Kloner, MD, PhD; Robert B. Jennings, MD
AbstractIn experimental studies in the dog, total proximal coronary artery occlusions of up to 15 minutes result in
reversible injury, meaning that the myocytes survive this insult. The 15 minutes of ischemia, however, induce numerous
changes in the myocardium, including certain monuments to the brief episode of ischemia that may persist for days. One
of these monuments is stunned myocardium, which represents prolonged postischemic contractile dysfunction of
myocardium salvaged by reperfusion. The mechanism of stunning involves generation of oxygen radicals as well as
alteration in calcium homeostasis and possibly alteration in contractile protein structure. Stunning has been observed in
several clinical scenarios, including after percutaneous transluminal coronary angioplasty, unstable angina, stressinduced ischemia, after thrombolysis, and after cardiopulmonary bypass. Oxygen radical scavengers and calcium
channel blockers have been shown to enhance function of stunned myocardium in experimental studies, and in a few
clinical studies, calcium channel blockers have been shown to ameliorate stunning. Although brief periods of ischemia
can contribute to prolonged left ventricular dysfunction and even heart failure, they paradoxically play a cardioprotective
role. Episodes of ischemia as short as 5 minutes, followed by reperfusion, protect the heart from a subsequent longer
coronary artery occlusion by markedly reducing the amount of necrosis that results from the test episode of ischemia.
This phenomenon, called ischemic preconditioning, has been observed in virtually every species in which it has been
studied and is a powerful cardioprotective effect. The mechanism of ischemic preconditioning involves both triggers and
mediators and involves complex second messenger pathways that appear to involve such components as adenosine,
adenosine receptors, the epsilon isoform of protein kinase C, the ATP-dependent potassium channels, as well as others,
including a paradoxical protective role of oxygen radicals. Both an early and a late phase of preconditioning have been
described, and the mechanisms underlying their induction are under investigation. That preconditioning may occur in
humans is suggested by the observations that repetitive balloon inflations in the coronary artery are associated with
progressively less chest pain, ST-segment elevation, lactate production, the protective effects of preinfarction angina, the
anginal warm-up phenomenon, and studies performed on human cardiac biopsies that show metabolic properties
suggesting preconditioning. Development of pharmacological agents that stimulate second messenger pathways thought
to be involved in preconditioning, but without causing ischemia, could result in novel approaches to treating ischemia.
Hence, on one hand, brief episodes of ischemia can have a negative effect on the heart: stunning; and on the other hand,
they have a protective effect: preconditioning. The future challenge is how to minimize the stunning phenomenon and
maximize the preconditioning phenomenon in clinical practice. (Circulation. 2001;104:3158-3167.)
Key Words: ischemia myocardium preconditioning myocardial infarction stunning, myocardial

fter a brief episode of ischemia, oxygen-derived free

radicals generated at the time of reperfusion damage the
myocytes and thereby cause much of the stunning effect.1
Most of these studies investigated brief periods of ischemia
(15 minutes) in animal models and showed that oxygen
radical scavengers could improve the return of function of the
stunned myocardium.29 Data regarding the effects of oxygen
radical scavengers on more prolonged periods of ischemia, as
would occur in a reperfused infarct, are mixed.10 There is

little information on the effect of oxygen radical scavenging

agents in human models of stunning. Although superoxide
dismutase did not benefit patients with myocardial infarction
undergoing reperfusion therapy,11 there are no data on the
effect of oxygen radical scavenging agents that cross the cell
membrane (such as N-2-mercaptopropionyl glycine) in this
situation.
Another approach to treating stunned myocardium has
been the administration of calcium channel blockers. In

From the Heart Institute, Good Samaritan Hospital, Keck School of Medicine, University of Southern California, Los Angeles (R.A.K.), and the
Pathology Department, Duke University Medical Center, Durham, NC (R.B.J.).
This is part 2 of a 2-part article. Part 1 appeared in Circulation, December 11, 2001 (Circulation. 2001;104:29812989).
Correspondence to Robert A. Kloner, MD, PhD, Heart Institute, Good Samaritan Hospital, 1225 Wilshire Blvd, Los Angeles, CA 90017. E-mail
rkloner@goodsam.org
2001 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org

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Kloner et al
experimental models of brief episodes of coronary artery
occlusion and reperfusion, nifedipine, verapamil, diltiazem,
and amlodipine were shown to enhance the return of cardiac
function.12 The exact mechanism by which the calcium
channel blockers work in these models is not clear. We
observed that small intracoronary doses of nifedipine that did
not alter hemodynamics or regional myocardial blood flow
nevertheless improved the function of stunned myocardium;
hence, it is probably not simply a function of afterload
reduction or induction of hyperemia.13 One possibility is a
direct cellular effect whereby the calcium blocker limits
influx of calcium into the injured but viable cell.
Recent clinical studies suggest that calcium channel blockers also enhance the recovery of stunned myocardium in
humans. Sheiban et al14 induced stunned myocardium in
patients by inflating a coronary angioplasty balloon for 5
minutes, followed by reperfusion. Patients received either
nitrate therapy or therapy with the calcium channel blocker
nisoldipine. Most patients pretreated with nitrates demonstrated stunning at 24 hours after the angioplasty, whereas
only 8% pretreated with nisoldipine showed stunning at 15
minutes after balloon deflation, and all had recovery of left
ventricular function by 1 day after reperfusion. Rinaldi et al15
also studied the effect of calcium channel blockade in patients
undergoing exercise stress echocardiograms by comparing
the effect of isosorbide mononitrate or amlodipine on postexercise wall motion abnormalities. As expected, shortening
fraction was better preserved in patients on amlodipine than
in those on nitrates. The use of calcium channel blockers to
treat stunning appears promising but remains investigational
at this time.
Stunned myocardium responds to inotropes, and although
this approach may not be a true treatment for the condition, it
is commonly used in the post cardiopulmonary bypass setting or in patients who demonstrate persistent left ventricular
dysfunction and severe heart failure after successful and
timely reperfusion.16 18 Arnold et al found that inotropic
stimulation of stunned myocardium did not worsen ultimate
recovery of the tissue or induce necrosis, as long as the artery
was fully patent.17 The theory on why inotropic stimulation
works relates to the concept that a mechanism of stunning is
desensitization of the myofilaments to calcium. It is likely
that inotropes simply overcome this desensitization by increasing the availability of calcium to the myofilaments.
What are the clinical implications of stunned myocardium?
Physicians should be aware that brief periods of ischemia can
be associated with prolonged contractile dysfunction. From a
practical standpoint, this is rarely an issue in the catheterization laboratory, because angioplasties usually are brief
enough not to cause prolonged systolic dysfunction. As
shown by Wijns et al,19 however, even brief balloon inflation
may cause relatively persistent diastolic dysfunction. Clinicians should be aware that the ultimate recovery of myocardium salvaged by reperfusion may not occur in the first few
days of therapy. Three days to several weeks may be
necessary, and some patients may demonstrate heart failure
due to stunning. Hence, inotropic support during the early
phase of reperfusion may be warranted. Stunning after cardiac surgery is common and may precipitate heart failure;

Consequences of Brief Ischemia

3159

again, inotropes are commonly used in these circumstances.

Stunning may occur in the setting of angina, even exerciseinduced angina. In most cases, the regional wall motion
abnormalities induced after a bout of exercise-induced ischemia resolve spontaneously and do not cause undue morbidity.
They could precipitate heart failure in some patients, however. Patients with unstable angina have exhibited stunning,
and again, the concern here is that this could induce heart
failure in some patients. The development of heart failure
symptoms in patients with extensive coronary artery disease
but without infarction is often referred to as ischemic cardiomyopathy. One potential contributing factor to this type of
cardiomyopathy may be stunning.
Finally, in the clinical realm, the term stunning has been
used (whether properly or not) to describe a phenomenon not
included in the original description. Left atrial stunning after
cardioversion refers to transient contractile dysfunction of the
left atrium after electrical or chemical cardioversion of atrial
fibrillation or flutter to sinus rhythm.20 The slow return of left
atrial function may be due in part to a tachycardia-induced
cardiomyopathy that occurred during the arrhythmia and/or
contributions from damage done during the cardioversion
itself. Reports suggest that recovery of left atrial function may
take up to several weeks and be associated with spontaneous
echocardiographic contrast, which implies stasis of flow in
the left atrium and may be a forerunner of thrombus formation. Hence, the clinical implication of this form of stunning
is that anticoagulation may need to be administered for 3 to 4
weeks after cardioversion.21

Relationship of Stunning to Hibernation

Hibernation is a concept coined by Diamond22 and popularized by Rahimtoola23 to explain how myocardium supplied
by a vessel with a fixed stenosis can remain alive and
persistently acontractile while receiving deficient arterial
flow. Rahimtoolas definition of this condition follows:
Hibernation is a state of persistently impaired myocardial
and left ventricular (LV) function at rest due to reduced
coronary blood flow that can be partially or completely
restored to normal if the myocardial oxygen supply/demand
relationship is favorably altered, either by improving blood
flow and/or by reducing demand.23 According to the results
of several kinds of studies, especially PET studies with
fluorodeoxyglucose, the acontractile tissue is still alive even
though arterial flow is depressed.24,25 Moreover, it can contract if arterial flow is restored.
The hibernation hypothesis proposes that the tissue has
downregulated its metabolism in response to the reduced
arterial flow and that this downregulation, just like hibernation in a bear or woodchuck, allowed the myocyte to survive
in a situation in which flow was insufficient to maintain
contraction. This concept has been difficult to study because
of the absence of a good animal model of chronic hibernation.
It is very difficult to detect complex alterations in metabolism
in human myocardium because direct sampling of the tissue
for long-term metabolic studies cannot be done. Nevertheless,
salvageable and potentially functional acontractile viable
tissue clearly exists in patients with severe coronary disease.
It remains to be proven that distinctive metabolic alterations

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December 18/25, 2001

are occurring in this tissue, but the fact that it is salvageable

and will function if appropriately treated is a very important
observation.
Stunning, like the concept of hibernating, refers to viable
myocardium that is not contracting properly but is not acutely
ischemic. Identifying such viable tissue in a poorly functioning heart is important in that this tissue eventually will
recover function if blood flow is restored. Remember, however, that necrotic or scar tissue, which is often present in
areas resupplied by a vessel with a significant stenosis, cannot
recover contractile function.
It was recently proposed that the functional state of defined
contractile failure of hibernation is due to chronic stunning
caused by multiple episodes of more severe ischemia brought
on by increases in oxygen demand, such as exercise, or
reduction of flow, as in coronary spasm, each followed by the
equivalent of reperfusion.26 28 This would result in a persistent stunned, acontractile state. Moreover, it has been possible
to model this condition in larger-animal hearts, such as pig
hearts.26 Other experimental studies, however, suggest that
hibernation does occur with a chronic low-flow state.29
Whether the acontractile state is due to downregulation of
metabolism or to chronic stunning, the treatment is clear:
arterial flow must be improved.

Time Course of Stunning

The time course of stunning is acute or subacute, on the order
of hours to weeks, depending on the degree and duration of
the initial ischemic insult. Brief episodes of ischemia of 15
minutes that might mimic angina and are not associated with
cell death require 48 hours for recovery (Figure).30 Once
the duration of ischemia is extended beyond 20 minutes and
cell death begins to occur in the subendocardium, recovery of
function may require days to perhaps even longer. Again,
stunning is typified by a prolonged recovery of function after
relief of a discrete episode of ischemia. Wall motion abnormalities that persist for months but occur within viable
myocardium may represent so-called hibernating myocardium, which represents a chronic phenomenon. There are some
histological features of hibernating tissue that differentiate it
from myocardium that has experienced one or few episodes
of stunning.24 Whereas the electron microscopic appearance
of stunned myocardium shows minimal change, hibernating
myocardium shows a pattern reminiscent of degenerating
cardiomyocytes, with large perinuclear pools of glycogen and
mitochondria and the presence of myofilaments limited to the
cell periphery.24 This loss of myofilaments probably contributes to the hibernating phenomenon and may help explain
why it is more of a chronic abnormality. The loss of
myofilaments also helps explain why some studies show that
revascularization of hibernating myocardium does not always
result in early dramatic improvement in function but that
months may be required for return of contractility.

Ischemic Preconditioning
Definition and Biology of Ischemic Preconditioning
Although episodes of transient myocardial ischemia can
induce the reversible injury of stunned myocardium, they can

Schematic of stunning and preconditioning. Short coronary

artery occlusions result in stunning, in which there is prolonged
regional wall motion abnormality, despite presence of reperfusion and viable myocardial cells. Brief episodes of ischemia/
reperfusion also precondition heart. When heart is then exposed
to a longer duration of ischemia and reperfusion, myocardial
infarct size is reduced.

also protect the heart from extensive necrosis. Murry et al31

first described the concept of ischemic preconditioning. In a
study reported in 1986, they reported that anesthetized dogs
subjected to 40 minutes of circumflex coronary artery occlusion and reperfusion demonstrated a marked reduction of
myocardial infarct size when the dogs received 4 brief
episodes of 5 minutes of ischemia separated by 5 minutes of
reperfusion just before the 40-minute occlusion. It was this
reduction in infarct size caused by the previous exposure of
the heart to brief episodes of ischemia that was referred to as
ischemic preconditioning.31 Analysis of the extent of necrosis
within the risk zone as a function of coronary collateral flow
showed an inverse relationship within the control animals.
The lower the coronary collateral flow, the greater the
percentage of the risk zone that went on to develop necrosis.
In the animals receiving ischemic preconditioning, this relationship was altered. Even in dogs with low coronary collateral flow, the extent of necrosis was reduced markedly with
preconditioning. Ischemic preconditioning subsequently was
shown to occur in rat, rabbit, pig, and mouse hearts. The
phenomenon was reproduced easily by a multitude of experimental laboratories.24 In the history of attempts to limit
myocardial infarct size via a host of interventions, such
consistency among laboratories was unprecedented.
Preconditioning can be induced by periods of ischemia as
short as 3 to 5 minutes followed by 5 minutes of reperfusion.
It is clear that a single episode of transient ischemia is all that

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Kloner et al
is needed to induce preconditioning,32,33 although laboratories
often use repetitive episodes of brief ischemia to induce the
phenomenon.34 If the duration between brief ischemia to
induce preconditioning and the more prolonged ischemic
episode to induce necrosis is extended from 5 minutes to 3
hours in the dog heart, the benefit of ischemic preconditioning disappears.4,31 If the duration between the ischemic
preconditioning episodes and the long-duration coronary
artery occlusion is extended to 24 to 96 hours, however, then
the protective effect returns and infarct size is reduced,
although not to as great an extent as when the long occlusion
occurs shortly after ischemic preconditioning.34,35 This later
phase of ischemic preconditioning originally was called the
second window of protection but now is best called delayed
or late preconditioning, whereas acute preconditioning is
often referred to as classic or early preconditioning. The
biology of classic preconditioning is summarized as follows:
It delays but does not prevent myocyte death during the test
episode of ischemia.31 Thus, if the duration of the test episode
of ischemia is excessive or reperfusion is not eventually
instituted, preconditioning will not work.36 It occurs in all
mammalian hearts tested thus far. The effects are maximal in
large-animal hearts, in which the metabolism and heart rates
are lower. Finally, as discussed under mechanisms, the
beneficial effect is present while energy demand is diminished in the preconditioned tissue.32,37 Myocardium may be
chronically preconditioned by repetitive brief occlusions, but
if the occlusions are too frequent and too close together,
tachyphylaxis can occur.38
Although the definition of ischemic preconditioning initially referred to reduction of infarct size, some investigators
have extended it to describe the protective effects of brief
ischemia on cardiac function and arrhythmias.39,40 These
latter protective effects have not been as consistent as effects
on infarct size. There are also ECG correlates of ischemic
preconditioning, including less ST-segment elevation on
subsequent brief coronary occlusions compared with a first
occlusion. Importantly, this phenomenon can be seen in
models of extremely low coronary collateral blood flow, such
as the rabbit, and therefore is not due to recruitment of
coronary collateral flow.41 Sebbag et al42 suggested that
attenuation of ST-segment elevation was immediate evidence
for the protective effect of preconditioning. Furthermore,
when the beneficial effect of preconditioning was lost after
120 or 180 minutes of reperfusion, the attenuation of STsegment elevation was also lost.

Mechanism(s) of Preconditioning
The mechanism(s) of ischemic preconditioning appears to be
complex and to involve second messenger pathways, as
suggested by the pioneering work of Downeys group.43 Also,
the mechanism of the delayed phase of preconditioning
differs in many ways from that of the early phase or classic
preconditioning.44
Our analysis of mechanisms will be limited to a consideration of protection against the key end point: cell death,45 and
not other end points such as arrhythmias,39,46 autonomic
denervation,47 or vascular responses. Mechanistic studies
have been performed in numerous models of preconditioning,

Consequences of Brief Ischemia

3161

including (1) preconditioned isolated rabbit,48 rat, neonatal

chicken,49 and human50 myocytes; (2) perfused rat,51 rabbit,52
or mouse hearts preconditioned in vitro; and (3) infarct sizing
in vivo in small rodents.5355 Where indicated, results from
these models will be included, but our discussion will
concentrate on findings in large-animal hearts, because these
changes are more likely to be relevant to preconditioning in
the human heart.
Myocardium that is fully preconditioned exhibits the striking metabolic changes noted earlier in the section on the
metabolic and physiological changes of reversible injury,
including a smaller adenine nucleotide pool (Ad), ie,
(ATPADPAMP), excess intracellular glucose, a creatine phosphate overshoot, and stunning.4,32 In addition, it
reacts to a second episode of ischemia much differently than
virgin myocardium in that it utilizes ATP and accumulates
lactate and H much more slowly.32,37,56,57 This situation of
slowed anaerobic glycolysis (the principal pathway of ATP
synthesis in severe ischemia) despite slowed depletion of
high energy phosphate (HEP) is best explained by hypothesizing that energy demand is reduced in ischemic preconditioned tissue.32,37,45,58 Because low intracellular ATP and high
tissue lactate and H are strongly associated with ischemic
cell death, it has been postulated that preconditioned tissue
dies more slowly because of this reduction in energy
demand.32,37
The change or changes that occur during the preconditioning episode of ischemia that trigger the preconditioning
response have not been identified with certainty.59 Also, the
changes that persist within the preconditioned tissue during
the reperfusion phase and either provide a memory of the
preconditioning event that changes the responses of the
myocardium to test ischemia or mediate the preconditioning
effect during the test episode of ischemia have not been
established.60

Triggers of Preconditioning With Ischemia

A trigger is considered to be a substance released during
ischemia and possibly during reperfusion that stimulates
signaling pathways in the myocytes that cause the changes
that allow myocytes to survive a test episode of ischemia
longer than virgin myocytes. Evidence for a putative trigger
would include the following: (1) the putative trigger increases
in concentration during ischemia; (2) administration of a
putative trigger to a coronary bed or myocardium itself
without ischemia will induce a state of pharmacological
preconditioning, ie, a state of protection similar to ischemic
preconditioning but caused by a drug rather than ischemia;
(3) administration of an inhibitor of the trigger will eliminate
the protection; and (4) this inhibitor will prevent preconditioning with ischemia. When an inhibitor to a putative trigger
prevents preconditioning caused by an episode of ischemia
and reperfusion, it follows that this trigger may be the cause
of preconditioning with ischemia in vivo.59

Mediators of Preconditioning With Ischemia

The protective effect caused by ischemia is hypothesized to
be caused by a mediator, ie, a change occurring intracellularly
as a consequence of the action of a trigger that then somehow

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December 18/25, 2001

protects against ischemia. There are 2 chief candidate mediators: the KATP channel61 65 and specific isoforms of protein
kinase C (PKC).59
The KATP channel, a channel found in high concentration in
the sarcolemma, opens whenever intracellular ATP declines
substantially, eg, to the levels found during a 5-minute
episode of ischemia in the dog heart. This effect of ischemia
can be blocked by pretreatment of the myocardium before the
preconditioning episode of ischemia with inhibitors of the
KATP channel, such as glibenclamide and 5-hydroxydecanoate
(5HD).63,64 These data support the idea that the KATP channel
is the mediator of the preconditioning effect. In addition,
there is a KATP channel in the mitochondria.65 This channel is
opened quite specifically by diazoxide and is blocked with
low concentrations of 5HD compared with the quantities of
5HD required to block the sarcolemmal KATP channel.66 Our
laboratory (R.B.J.) has shown that pretreatment with diazoxide pharmacologically preconditions the dog heart and reduces infarct size to much the same extent as preconditioning
with ischemia, although this effect is less marked in the in
vivo rabbit model.67 Thus, there are strong data supporting
the idea that a trigger exerts its effect by opening the
mitochondrial KATP channel and that this somehow mediates
the protective effect.62,66
Although there is much evidence that KATP channels are
mediators, Downeys group (Downey and Cohen61; Pain et
al68) recently presented evidence gathered in the isolated
perfused rabbit heart that indicates that KATP channel activation in the mitochondria may be a trigger rather than a
mediator. This issue remains to be resolved,61,69 as does the
question of how opening the mitochondrial KATP channel
provides protection.
The second proposed mediator is the epsilon isoform of
PKC. This isoform of this kinase (but not total PKC) is
translocated during ischemia.60,70 73 When active, it phosphorylates serine and threonine groups in enzyme or channel
proteins and presumably exerts its effect through this phosphorylation. This phenomenon has been difficult to study in
vivo because many of the potential agonists and inhibitors are
insoluble in water and because the inhibitors often are not as
specific as is desirable.60 Thus, most studies of this potential
mechanism have been performed in vitro in perfused rat or
rabbit heart, in which inhibition of its action with inhibitors
such as chelerythrine blocks the beneficial effect of preconditioning with ischemia.59
In addition, some kinases, probably downstream from
PKC, such as ERK and the tyrosine kinases Src and Lck,
appear to be involved.74 Again, the inhibitors of their action
are generally insoluble in water and cannot be administered
easily in vivo. Nevertheless, Vahlhaus et al74 have shown that
inhibition of both PKC and tyrosine kinase will prevent
ischemic preconditioning in the pig heart, whereas inhibition
of PKC alone has no effect.75

Adenosine
This nucleoside is released quickly into the extracellular fluid
very early in ischemia and is present in concentrations greater
than those required to stimulate the receptor. Thus, it is a
potential trigger. Also, it has been shown in vivo in both

rabbit76 and dog77 hearts that adenosine or A1 agonists of

adenosine will pharmacologically precondition the heart
against the effects of a test episode of ischemia.78 Moreover,
these effects can be blocked by administration of an inhibitor
of the adenosine effect such as 8-(p-sulfophenyl)theophylline76 or by the KATP channel inhibitor glibenclamide.77 The results of these experiments, taken together,
provide strong evidence that adenosine is involved in preconditioning with ischemia and the potassium channel is involved in mediating the effect of adenosine. Also, good data
exist that the beneficial effect of adenosine is mediated via the
A1 receptor76,78 and that this receptor stimulates PKC isoform
translocation (activation).43

Other Triggers
Administration of bradykinin79,80 and opioids81,82 will induce
pharmacological preconditioning. Bradykinin and opioids are
released during the preconditioning episode of ischemia on a
time scale consistent with these agents being involved in the
phenomenon. In addition, the observation that the beneficial
effects of preconditioning with ischemia are eliminated or
reduced by inhibitors of bradykinin and opioids indicates that
these agents can act as triggers.81 Thus, it seems likely that
there are a series of triggers in preconditioning. Downeys
group has provided some evidence indicating that they may
act synergistically.80

How Is Myocyte Death Delayed

in Preconditioning?
A major mechanism proposed to explain why preconditioned
myocytes tolerate ischemia better than virgin myocytes is that
the reduced energy demand found in ischemic preconditioned
tissue preserves ATP and slows the development of the
osmotic load and acidosis.37 Slowing of the development of
these changes, both of which are an invariable accompaniment of ischemic cell death, is consistent with a delay of the
transition to irreversibility.83
Another unexpected change involves O2-derived free radicals appearing during reperfusion. Murry et al84 showed in
1988 that intravenous administration of the free radical
scavengers superoxide dismutase and catalase would prevent
preconditioning with ischemia in many but not all dog hearts.
These data suggested that free radicals exerted a paradoxical
protective rather than deleterious effect in reperfused ischemic myocardium. It was recently suggested that the effect of
opening potassium channels in mitochondria with diazoxide
and thereby preconditioning the heart is to increase O2derived free radical production from the mitochondria.68
These O2-derived free radicals could mediate the protective
effect through some as yet unknown mechanism that appears
to involve mitochondria.68 An attempt to show that the
mitochondrial ATPase, one of the chief sources of ATP
utilization during ischemia, was inhibited more quickly during the prolonged episode of ischemia, a change that would
slow ATP depletion, was unsuccessful.85

Genetic Responses
It has seemed unlikely that classic preconditioning is mediated by any new protein synthesis. This is because precondi-

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Kloner et al

Consequences of Brief Ischemia

3163

Clinical Situations in Which Preconditioning May Occur

Entity

Comment

Repetitive balloon inflations during PTCA

Less chest pain, ST elevation, lactate with sequential inflations.

Pharmacological preconditioning may mimic effects of brief ischemia

Preinfarct angina

Associated with smaller infarcts, improved clinical outcomes. Debate in

elderly patients

Warm-up phenomenon

Less angina and ECG signs of ischemia when second exercise period
occurs after short rest

Studies in human tissue

Isolated human cardiomyocytes

Exhibit preconditioning-like properties when exposed to simulated

ischemia/reoxygenation. Pharmacological preconditioning has been
demonstrated

Isolated human muscle strips

Exhibit preconditioning-like properties and enhanced function with

preconditioning ischemia before longer-duration ischemia

Biopsies taken from human cardiac tissue at

time of coronary artery bypass surgery

Intermittent aortic cross-clamping mimics preconditioning, preserves

cardiac ATP levels

tioning can be induced so quickly, eg, by 3 to 5 minutes of

ischemia and 5 minutes of reperfusion. Also, inhibition of
protein synthesis with cyclohexamide and RNA synthesis
with actinomycin D86 has no effect on preconditioning with
ischemia, an observation that indicates that effective gene
activation has not occurred in the brief interval required to
precondition in classic preconditioning.

Delayed or Late Preconditioning

This phenomenon is of great interest (see section on delayed
preconditioning and stunning) for 3 reasons. The first is that
the preconditioning episode of ischemia clearly causes new
enzyme synthesis. Included are inducible NO synthase, superoxide dismutase, and heat-shock proteins. Some or all of
these proteins may be involved in the protection. The second
is the fact that the protective effect persists for 48 hours. It
appears to be slightly weaker than the protection wrought by
classic preconditioning but is easy to demonstrate in rabbits,
pigs, and dogs. The third reason that delayed preconditioning
is noteworthy is that O2-derived free radicals, probably
peroxynitrite, are involved in inducing the protection, in that
one can eliminate late preconditioning by pretreatment with a
free radical scavenger before the preconditioning episodes of
ischemia.87 Because there is indirect evidence that O2-derived
free radicals are involved in the protection noted in classic
preconditioning, it is likely that different free radicals mediate
the effect, because NO does not appear to be involved in
classic preconditioning.88

Preconditioning in Patients
Preconditioning has been demonstrated in experimental studies
of all species that have been tested. Clinical studies also support
the concept that preconditioning occurs in humans (Table).89 91
When isolated human myocardial cells in culture are exposed to
severe hypoxia for 90 minutes followed by reoxygenation, some
cells will die, and the extent of cell death can be quantified by
trypan blue exclusion. Ikonomidis et al50 showed that exposing
the cells to briefer periods of hypoxia and reoxygenation before
the longer 90-minute duration of test hypoxia significantly
reduced cell death. This observation is very important, for 2
reasons: first, it suggests that human myocardial cells can be

preconditioned; second, it suggests that other cell types are not

needed for preconditioning. The benefit of ischemic preconditioning thus depends on primary biochemical changes within the
myocyte itself and not on changes in the vasculature or other
interstitial cells. This finding agrees with the general observation
that ischemic preconditioning is not dependent on recruitment of
collateral blood vessels, because species without collaterals,
such as rats, pigs, and rabbits, all can be preconditioned.
Other studies suggest that human myocardial tissue can be
preconditioned. Yellon and associates (Walker et al92;
Speechly-Dick et al93) showed that biopsies taken from
human hearts undergoing surgery display properties suggesting preconditioning. Brief episodes of ischemia preserved
cardiac enzymes and function of isolated human cardiac
muscle when exposed to longer periods of in vitrosimulated
ischemia. Preconditioning-mimetic agents (pharmacological
agents thought to work along the same pathways as ischemic
preconditioning) also appeared to precondition human tissue.
Yellon and associates90 showed that intermittent aortic crossclamping could precondition human left ventricles during
coronary artery bypass surgery, resulting in a preservation of
ATP levels.
In addition to studies involving assessment of human
cardiac tissue, there are several clinical scenarios that suggest
that ischemic preconditioning occurs in humans.89,94 PTCA
has provided insight into the effects of brief episodes of
ischemia on the human heart. When repetitive balloon inflations (usually on the order of 60 to 90 seconds) and deflations
are performed, the following clinical observations have been
made: (1) the severity of chest pain lessens with subsequent
compared with a first balloon inflation, (2) the degree of
ST-segment elevation is reduced with subsequent balloon
inflations, (3) the degree of lactate production is reduced with
subsequent compared with a first inflation, and (4) the
phenomenon occurs in patients who do not appear to recruit
collaterals.89,94,95
The sequential angioplasty balloon inflation model may be
a useful screening tool whereby pharmacological agents that
mimic preconditioning but do not cause ischemia can be
tested. It has been observed that preconditioning mimetics,
such as adenosine or nicorandil,94,96,97 reduce the subsequent

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December 18/25, 2001

amount of ST changes. Conversely, agents that are known to

block preconditioning pathways, such as the KATP channel
blocker glibenclamide, were shown to prevent the beneficial
effects of repetitive balloon inflation.98 From a practical
standpoint, difficult angioplasties associated with severe ischemia during initial balloon inflation and not amenable to
stent placement might benefit from a preconditioning protocol of sequential brief inflations and deflations.
Several clinical studies now suggest that brief episodes of
ischemia in the form of angina occurring within the first day
or so before acute myocardial infarction may have protective
effects.99 102 In one thrombolytic study from the TIMI-4
group,99 preinfarction angina was associated with a smaller
infarct size as assessed by creatine kinase curves, fewer
in-hospital deaths, and less congestive heart failure and/or
shock. There was no difference in coronary collateral scores
between patients with versus those without preinfarction
angina, and the benefit was not due to use of antianginal
drugs or aspirin. In a more recent study from the TIMI-9
group in which the timing of angina in relationship to
myocardial infarction was evaluated, only those patients with
angina within 24 hours of infarction derived benefits on
infarct size or clinical outcomes from the preinfarction
angina.103 Numerous other thrombolytic trials have suggested
that preinfarction angina can reduce myocardial infarct size in
patients, improve survival, improve left ventricular function,
and reduce arrhythmias.94,99 103 Although classic preconditioning might play some role in these phenomena, it is likely
that episodes of pain occurring closer to 1 day before
infarction, as well as silent ischemia which may occur at this
time, may be having a benefit through the delayed preconditioning mechanism. Andreotti et al104 made the fascinating
observation that the benefit of preinfarction angina may be
related to better and faster thrombolysis, implying that
preinfarction angina might induce a vascular preconditioning
effect. For example, brief periods of ischemia due to angina
that occur before myocardial infarction might release adenosine that could then interfere with platelet aggregation.
Not all preinfarction angina studies have been positive. In
one recent report, preinfarction angina had no benefit when
the infarct was reperfused by PTCA rather than
thrombolysis.105 This observation would tend to support the
findings of Andreotti et al.104 There is also debate as to
whether preinfarction angina has any benefit in elderly
patients. Some studies have shown benefits in the elderly, but
others have not.106 109
Another clinical manifestation of ischemic preconditioning
is the so-called warm-up phenomenon.89,94,110 112 In this
common clinical scenario, patients with angina exercise to the
point of angina, stop, rest, and then are able to continue
exertion without further angina. When patients received
exercise tests, rested for 15 minutes, and then repeated the
exercise tests, they showed better exercise tolerance and had
less ST-segment depression on the second than the first
test.110 Regional myocardial oxygen consumption was lower
during the second test than the first, and flow through the
cardiac vein did not differ between tests. Williams et al111
induced angina by pacing-induced tachycardia at the time of
catheterization. Two identical periods of pacing were sepa-

rated by a 5- to 15-minute rest phase. The extent of STsegment depression and the severity of angina were reduced
during the second bout of pacing. Coronary blood flow did
not differ between the 2 pacing episodes, suggesting that
large amounts of coronary collateral flow were not being
recruited during the second period; regional myocardial
oxygen consumption decreased during the second period of
pacing. Other studies have demonstrated this type of warm-up
phenomenon and have related it to the early but not to the late
phase of ischemic preconditioning.112

Preconditioning as Therapy
Can ischemic preconditioning be used to treat cardiovascular
disorders? Over the past 15 years, a large volume of research
has focused on the mechanisms of both early and late
ischemic preconditioning.43,44 Results of these studies have
suggested that ischemic preconditioning involves second
messenger pathways43 that theoretically could be stimulation
and thereby induce the beneficial effects of ischemic preconditioning without ischemia. Conversely, the inhibition of
various aspects of these pathways can prevent ischemic
preconditioning. Development of preconditioning mimetic
agents has shown promise in experimental studies. Examples
include adenosine, adenosine agonists, PKC agonists, KATP
channel openers, and NO donors.43,44 Translating these beneficial agents to the clinical realm has been tricky, because
many of these agents have profound hemodynamic effects.
For example, whereas diazoxide, a mitochondrial KATP channel opener, mimicked preconditioning and reduced cell death
in several animal models, it also causes significant hypotension in humans. Nevertheless, some preconditioning mimetic
agents already are used clinically, although their use may not
be based primarily on the preconditioning concept. Nicorandil is a KATP channel opener that reduced angina.113 It is
currently on the market in Japan and in parts of Europe.
Adenosine has shown promise when given as an adjunct to
cardioplegia; in this setting, it appears to decrease the need
for use of high-dose inotropes after cardiac surgery.114 Adenosine also is being tested as an adjunct to reperfusion in
patients with acute myocardial infarction. In the AMISTAD I
trial,115 adenosine reduced infarct size in patients with anterior myocardial infarction. Whether the benefit of adenosine
was related to a preconditioning mechanism is not clear,
because the drug was given not at preocclusion but at
reperfusion.
In what clinical scenarios could preconditioning mimetics
be useful? Most data in the experimental literature suggest
that preconditioning mimetics would need to be given before
occlusion to attain a true preconditioning effect with reduction of infarct size at the time of thrombolysis. Unfortunately,
this will not be possible in the clinical setting of acute
myocardial infarction, unless the patient is taking an oral
medicine long-term. And even that might not work, because
long-term therapy with a preconditioning mimetic might lead
to tachyphylaxis. However, this has never been established
experimentally. If tachyphylaxis does not develop, giving
preconditioning mimetics to patients at risk of infarction for
the purpose of delaying cell death before reperfusion is
possible, but only if the agent is relatively nontoxic and has

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Kloner et al
few side effects. Preconditioning mimetic agents clearly can
be applied to reduce ischemic damage, when the period of
ischemia is controlled and predicted. Two clinical situations
that might benefit from preconditioning mimetics would be
before cardiopulmonary bypass or to a heart at the time of
removal for transplantation. Providing these agents to patients
with unstable angina in which the mimetic might augment the
protective effect of angina itself is another area that deserves
further study. As mentioned, KATP channel blockers may show
promise in this regard. A preconditioning agent might prevent
or reduce the amount of necrosis should the patient develop a
myocardial infarction. Such an agent could reduce the amount
of ischemia that develops during a high-risk angioplasty
procedure in which the occluded vessel supplies a very large
risk area. Of course, another approach would be to perform
multiple brief balloon inflations that would ischemically
precondition the heart. With the advent of stents and perfusion catheters, however, it is unlikely that preconditioning
mimetics would have a great practical clinical role in the
catheterization laboratory. Finally, preconditioning mimetics
might be useful for patients with exercise-induced angina that
is not fully controlled by the usual drugs. Taking such agents
before an episode of planned exertion might stave off angina.
Hence, although preconditioning is one of the most powerful
techniques for reducing ischemic necrosis during coronary
artery occlusion, its translation into practical use in the clinic
will still require significant research and clinical trials before
preconditioning mimetics become standard therapy for ischemic syndromes.

References
1. Bolli R. Mechanism of myocardial stunning. Circulation 1990;82:
723738.
2. Myers ML, Bolli R, Lekich RF, et al. Enhancement of recovery of
myocardial function by oxygen free radical scavengers after reversible
regional ischemia. Circulation. 1985;72:915921.
3. Przyklenk K, Kloner RA. Superoxide dismutase plus catalase improve
contractile function in the canine model of the stunned myocardium.
Circ Res. 1986;58:148 156.
4. Murry CE, Richard VJ, Jennings RB, et al. Myocardial protection is lost
before contractile function recovers from ischemic preconditioning.
Am J Physiol. 1991;260:H796 H804.
5. Bolli R, Jeroudi MO, Patel BS, et al. Direct evidence that oxygenderived free radicals contribute to postischemic myocardial dysfunction
in the intact dog. Proc Natl Acad Sci U S A. 1989;86:4695 4699.
6. Jeroudi MO, Triana FJ, Patel BS, et al. Effect of superoxide dismutase
and catalase, given separately, on myocardial stunning. Am J Physiol.
1990;259:H889 H901.
7. Gross GJ, Farber NE, Hardman HF, et al. Beneficial actions of
superoxide dismutase and catalase in stunned myocardium of dogs. Am J
Physiol. 1986;250:H372H377.
8. Bolli R, Patel BS, Jeroudi MO, et al. Demonstration of free radical
generation in stunned myocardium of intact dogs with the use of the
spin trap alpha-phenyl N-tertiary butyl nitrone. J Clin Invest. 1988;82:
476 485.
9. Bolli R, Jeroudi MO, Patel BS, et al. Marked reduction of free radical
generation and contractile dysfunction by antioxidant therapy begun at
the time of reperfusion: evidence that myocardial stunning is a manifestation of reperfusion injury. Circ Res. 1989;65:607 622.
10. Przyklenk K, Kloner RA. Reperfusion injury by oxygen-free radicals?
Effect of superoxide dismutase plus catalase, given at the time of
reperfusion, on myocardial infarct size, contractile function, coronary
microvasculature, and regional myocardial blood flow. Circ Res. 1989;
64:86 96.
11. Flaherty JT, Pitt B, Gruber JW, et al. Recombinant human superoxide
dismutase (h-SOD) fails to improve recovery of ventricular function in

12.
13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.
24.

25.

26.

27.
28.

29.
30.

31.

32.

33.

34.

35.

Consequences of Brief Ischemia

3165

patients undergoing coronary angioplasty for acute myocardial

infarction. Circulation. 1994;89:19821991.
Przyklenk K, Kloner RA. Calcium antagonists and the stunned myocardium. J Cardiovasc Pharmacol. 1991;18(suppl 10):S93S101.
Przyklenk K, Ghafari GB, Eitzman DT, et al. Nifedipine administered
post reperfusion ablates systolic contractile dysfunction of postischemic
stunned myocardium. J Am Coll Cardiol. 1989;13:1176 1183.
Sheiban I, Tonni S, Marini A, et al. Clinical and therapeutic implications
of chronic left ventricular dysfunction in coronary artery disease. Am J
Cardiol. 1995;73:23E30E.
Rinaldi CA, Linka AZ, Masaini ND, et al. Randomized, double-blind
crossover study to investigate the effects of amlodipine and isosorbide
mononitrate on the time course and severity of exercise-induced myocardial stunning. Circulation. 1998;98:749 756.
Ellis JG, Wynne J, Braunwald E, et al. Response of reperfusion-salvaged
stunned myocardium to inotropic stimulation. Am Heart J. 1984;107:
1319.
Arnold JMO, Braunwald E, Sandor T, et al. Inotropic stimulation of
reperfused myocardium: effects on infarct size and myocardial function.
J Am Coll Cardiol. 1985;6:1026 1034.
Becker LC, Levine JH, DiPaula AF, et al. Reversal of dysfunction in
post ischemic stunned myocardium by epinephrine and post extra systolic potentiation. J Am Coll Cardiol. 1986;7:580 589.
Wijns W, Serruys PW, Slager CJ, et al. Effect of coronary occlusion
during percutaneous transluminal angioplasty in humans on left ventricular chamber stiffness and regional diastolic pressure radius relations.
J Am Coll Cardiol. 1986;7:455 461.
Fatkin D, Kuchan DL, Thorburn CW, et al. Transesophageal echocardiography before and during direct current cardioversion of atrial fibrillation: evidence of atrial stunning as a mechanism of thromboembolic
complications. J Am Coll Cardiol. 1994;23:307316.
Grimm RA, Steward WJ, Maloney JD, et al. Impact of electrical cardioversion for atrial fibrillation on left atrial appendage function and
spontaneous echo contrast characterization by simultaneous transesophageal echocardiography. J Am Coll Cardiol. 1993;22:1359 1366.
Diamond GA, Forrester JS, de Luz PL, et al. Post-extrasystolic potentiation of ischemic myocardium by atrial stimulation. Am Heart J.
1978;95:204 209.
Rahimtoola SH. The hibernating myocardium. Am Heart J. 1989;117:
211221.
Kloner RA, Bolli R, Marban E, et al. Medical and cellular implications
of stunning, hibernation, and preconditioning: an NHLBI Workshop.
Circulation. 1998;97:1848 1867.
Tillisch J, Brunken R, Marshall R, et al. Reversibility of cardiac wall
motion abnormalities predicted by positron emission tomography.
N Engl J Med. 1986;314:884 888.
Shen Y-T, Vatner SF. Mechanism of impaired myocardial function
during progressive coronary stenosis in conscious pigs: hibernation
versus stunning? Circ Res. 1995;73:479 488.
Wijns W, Vatner SF, Camici PG. Hibernating myocardium. N Engl
J Med. 1998;339:173181.
Camici PG, Dutka DP. Repetitive stunning, hibernation, and heart
failure: contribution of PET to establishing a link. Am J Physiol. 2001;
280:H929 H936.
St. Louis JD, Hughes GC, Kypson AP, et al. An experimental model of
chronic myocardial hibernation. Ann Thorac Surg. 2000;69:13511357.
Bolli R, Zhu WX, Thornby JI, et al. Time-course and determinants of
recovery of function after reversible ischemia in conscious dogs. Am J
Physiol. 1988;254:H102H114.
Murry CE, Jennings RB, Reimer KA. Preconditioning with ischemia: a
delay of lethal cell injury in ischemic myocardium. Circulation. 1986;
14:1124 1136.
Jennings RB, Sebbag L, Schwartz LM, et al. Metabolism of preconditioned myocardium: effect of loss and reinstatement of cardioprotection.
J Mol Cell Cardiol. 2001;33:15711588.
Miura T, Goto M, Urabe K, et al. Does myocardial stunning contribute
to infarct size limitation by ischemic preconditioning? Circulation.
1991;84:2504 2512.
Kuzuya T, Hoshida S, Yamashita N, et al. Delayed effects of sublethal
ischemia on the acquisition of tolerance to ischemia. Circ Res. 1993;
72:12931299.
Marber MS, Latchman DS, Walker JM, et al. Cardiac stress protein
elevation 24 hours after brief ischemia or heat stress is associated with
resistance to myocardial infarction. Circulation. 1993;88:1264 1272.

Downloaded from http://circ.ahajournals.org/ by guest on March 26, 2012

3166

Circulation

December 18/25, 2001

36. Murry CE, Jennings RB, Reimer KA. What is ischemic preconditioning?
In: Przyklenk K, Kloner RA, Yellon DM, eds. Ischemic Preconditioning: The Concept of Endogenous Cardioprotection. Boston, Mass:
Kluwer Academic Publishers; 1994:317.
37. Murry CE, Richard VJ, Reimer KA, et al. Ischemic preconditioning
slows energy metabolism and delays ultrastructural damage during a
sustained ischemic episode. Circ Res. 1990;66:913931.
38. Cohen MV, Yang XM, Downey JM. Conscious rabbits become tolerant
to multiple episodes of ischemic preconditioning. Circ Res. 1994;74:
998 1004.
39. Hagar JM, Hale SL, Kloner RA. Effects of preconditioning ischemia on
reperfusion arrhythmias after coronary artery occlusion and reperfusion
in the rat. Circ Res. 1991;68:61 68.
40. Ovize M, Kloner RA, Przyklenk K. Preconditioning and myocardial
contractile function. In: Przyklenk K, Kloner RA, Yellon DM, eds.
Ischemic Preconditioning: The Concept of Endogenous Cardioprotection. Boston, Mass: Kluwer Academic Publishers; 1994:41 60.
41. Birnbaum Y, Hale SL, Kloner RA. Progressive decrease in the ST
segment elevation during ischemic preconditioning: is it related to
recruitment of collateral vessels? J Mol Cell Cardiol. 1996;28:
14931499.
42. Sebbag L, Brooks SE, Jennings RB, et al. Cardioprotection, lost 3 hours
after ischemic preconditioning (PC) can be fully restored by repeated
preconditioning in dogs: significance of ST-segment changes for
detecting cardioprotection. Eur Heart J. 1997;18:162.
43. Cohen MV, Baines CP, Downey JM. Ischemic preconditioning from
adenosine receptor to KATP channel. Annu Rev Physiol. 2000;62:79 109.
44. Bolli R. The late phase of preconditioning. Circ Res. 2000;87:972983.
45. Jennings RB, Reimer KA. Discovery and early history of preconditioning. In: Heyndrickx GR, Vatner S, Wijns W, eds. Stunning, Hibernation, and Preconditioning: Clinical Pathophysiology of Myocardial
Ischemia. Philadelphia, Pa: Lippincott-Raven Publishers; 1997:83104.
46. Lawson CS, Coltart DJ, Hearse DJ. The antiarrhythmic action of
ischaemic preconditioning in rat hearts does not involve functional Gi
proteins. Cardiovasc Res. 1993;27:681 687.
47. Miyazaki T, Zipes DP. Protection against autonomic denervation following acute myocardial infarction by preconditioning ischemia. Circ
Res. 1989;64:437 448.
48. Armstrong S, Downey JM, Ganote CE. Preconditioning of isolated
cardiomyocytes: induction by metabolic stress and blockade by the
adenosine antagonist SPT and calphostin C, a protein kinase C inhibitor.
Cardiovasc Res. 1994;28:7277.
49. Liang BT. Protein kinase C-dependent activation of KATP channel
enhances adenosine-induced cardioprotection. Biochem J. 1998;336:
337343.
50. Ikonomidis JS, Tumiati LC, Weisel RD, et al. Preconditioning human
ventricular cardiomyocytes with brief periods of simulated ischaemia.
Cardiovasc Res. 1994;28:12851291.
51. Steenbergen C Jr, Perlman ME, London RE, et al. Mechanism of
preconditioning: ionic alterations. Circ Res. 1993;72:112125.
52. Ytrehus K, Liu Y, Tsuchida A, et al. Rat and rabbit heart infarction:
effects of anesthesia, perfusate, risk zone, and method of infarct sizing.
Am J Physiol. 1994;267:H2383H2390.
53. Li Y, Whittaker P, Kloner RA. The transient nature of the effects of
ischemic preconditioning on myocardial infarct size and ventricular
arrhythmia. Am Heart J. 1992;123:346 353.
54. Liu Y, Downey JM. Ischemic preconditioning protects against infarction
in rat heart. Am J Physiol. 1992;263:H1107H1112.
55. Yellon DM, Alkhulaifi AM, Browne EE, et al. Ischaemic preconditioning limits infarct size in the rat heart. Cardiovasc Res. 1992;26:
983987.
56. Fleet WF, Johnson TA, Graebner CA, et al. Effect of serial brief
ischemic episodes on extracellular K, pH, and activation in the pig.
Circulation. 1985;72:922932.
57. Weiss RG, de Albuquerque CP, Vandegaer K, et al. Attenuated glycogenolysis reduces glycolytic catabolite accumulation during ischemia in
preconditioned rat hearts. Circ Res. 1996;79:435 446.
58. Reimer K, Hill ML, Jennings RB. Prolonged depletion of ATP and of
the adenine nucleotides pool due to delayed resynthesis of adenine
nucleotides following reversible myocardial ischemic injury in dogs. J
Mol Cell Cardiol. 1981;13:229 239.
59. Downey JM, Yellon DM. The biology of preconditioning. In: Heyndrickx
GR, Vatner SF, Wijns W, eds. Stunning, Hibernation and Preconditioning:
Clinical Pathophysiology of Myocardial Ischemia. Philadelphia, Pa:
Lippincott-Raven Publishers; 1997:105119.

60. Jennings RB. Role of protein kinase C in preconditioning with ischemia

against lethal cell injury. Basic Res Cardiol. 1997;92(suppl 2):40 42.
61. Downey JM, Cohen MV. Mitochondrial KATP channel opening during
index ischemia and following myocardial reperfusion in ischemic rat
hearts. J Mol Cell Cardiol. 2001;33:651 653.
62. Fryer RM, Hsu AK, Gross GJ. Mitochondrial KATP channel opening is
important during index ischemia and following myocardial reperfusion
in ischemic preconditioned rat hearts. J Mol Cell Cardiol. 2001;33:
831 834.
63. Yao Z, Cavero I, Gross GJ. Activation of cardiac KATP channels: an
endogenous protective mechanism during repetitive ischemia. Am J
Physiol. 1993;264:H495H504.
64. Auchampach JA, Grover CJ, Gross GJ. Blockade of ischemic preconditioning in dogs by the novel ATP dependent potassium channel antagonist sodium 5-hydroxydecanoate. Cardiovasc Res. 1992;26:
1054 1062.
65. Garlid KD, Paucek P, Yarov-Yarovoy V, et al. The mitochondrial KATP
channel as a receptor for potassium channel openers. J Biol Chem.
1996;271:8796 8799.
66. Garlid KD, Paucek P, Yarov-Yarovoy V, et al. Cardioprotective effect
of diazoxide and its interaction with mitochondrial ATP-sensitive K
channels. Circ Res. 1997;81:10721082.
67. Hale SL, Kloner RA. Effect of combined KATP channel activation and
Na/H exchange inhibition on infarct size in rabbits. Am J Physiol.
2000;279:H2673H2677.
68. Pain T, Yang X-M, Critz CD, et al. Opening of mitochondrial KATP
channels triggers the preconditioned state by generating free radicals.
Circ Res. 2000;87:460 466.
69. Gross GJ, Fryer RM. Mitochondrial KATP channels: triggers or distal
effectors of ischemic or pharmacologic preconditioning? Circ Res. 2000;
87:431 433.
70. Ping P, Zhang J, Qiu Y, et al. Ischemic preconditioning induces selective
translocation of PKC isoforms and in the heart of conscious rabbits
without subcellular redistribution of total PKC activity. Circ Res. 1997;
81:404 414.
71. Ping P, Zhang J, Zheng YT, et al. Demonstration of selective protein
kinase C-dependent activation of Src and Lck tyrosine kinases during
ischemic preconditioning in conscious rabbits. Circ Res. 1999;85:
542550.
72. Ping P, Takano H, Zhang J, et al. Isoform-selective activation of protein
kinase C by nitric oxide in the heart of conscious rabbits. Circ Res.
1999;84:587 604.
73. Przyklenk K, Sussman MA, Simkhovich BZ, et al. Does ischemic
preconditioning trigger translocation of protein kinase C in the canine
model? Circulation. 1995;921:1546 1557.
74. Vahlhaus C, Schulz R, Post H, et al. Prevention of ischemic preconditioning only by combined inhibition of protein kinase C and protein
tyrosine kinase in pigs. J Mol Cell Cardiol. 1998;30:197209.
75. Vahlhaus C, Schulz R, Post H, et al. No prevention of ischemic preconditioning by the protein kinase C inhibitor staurosporine in swine. Circ
Res. 1996;79:407 414.
76. Liu GS, Thornton J, VanWinkle DM, et al. Protection against infarction
afforded by preconditioning is mediated by A1 adenosine receptors in
rabbit heart. Circulation. 1991;84:350 356.
77. Grover GJ, Sleph PG, Dzwonczyk S. Role of myocardial ATP-sensitive
potassium channels in mediating preconditioning in the dog heart and
their possible interaction with adenosine A1-receptors. Circulation.
1992;86:1310 1316.
78. Takano H, Bolli R, Black RG, et al. A1 or A3 adenosine receptors induce
late preconditioning against infarction in conscious rabbits by different
mechanisms. Circ Res. 2001;88:520 528.
79. Wall TM, Sheehy R, Hartman JC. Role of bradykinin in myocardial
preconditioning. J Pharmacol Exp Ther. 1994;270:681 690.
80. Goto M, Liu Y, Yang X-M, et al. Role of bradykinin in protection of
ischemic preconditioning in rabbit hearts. Circ Res. 1995;77:611 621.
81. Schultz JEJ, Rose E, Yao Z, et al. Evidence for involvement of opioid
receptors in ischemic preconditioning in rat hearts. Am J Physiol. 1995;
268:H2157H2161.
82. Schwartz LM, Jennings RB, Reimer KA. Premedication with the opioid
analgesic butorphanol raises the threshold for ischemic preconditioning
in dogs. Basic Res Cardiol. 1997;92:106 114.
83. Jennings RB, Reimer KA, Steenbergen C Jr. Myocardial ischemia
revisited: the osmolar load, membrane damage, and reperfusion. J Mol
Cell Cardiol. 1986;18:769 780.

Downloaded from http://circ.ahajournals.org/ by guest on March 26, 2012

Kloner et al
84. Murry CE, Richard VJ, Jennings RB, et al. Preconditioning with ischemia: is the protective effect mediated by free radical-induced myocardial
stunning? Circulation 1988;78(suppl II):II-77. Abstract.
85. VanderHeide RS, Hill ML, Steenbergen C Jr, et al. Effect of reversible
ischemia on the activity of the mitochondrial ATPase: relationship to
ischemic preconditioning. J Mol Cell Cardiol. 1996;28:103112.
86. Thornton J, Striplin S, Liu GS, et al. Inhibition of protein synthesis does
not block myocardial protection afforded by preconditioning. Am J
Physiol. 1990;259:H1822H1825.
87. Tang X-L, Rizvi AN, Qui Y, et al. Evidence that the hydroxyl radical
triggers late preconditioning against myocardial stunning in conscious
rabbits. Circulation. 1997;96(suppl I):I-255. Abstract.
88. Weselcouch EO, Baird AJ, Sleph P, et al. Inhibition of nitric oxide
synthesis does not affect ischemic preconditioning in isolated perfused
rat hearts. Am J Physiol. 1995;37:H242H249.
89. Kloner RA, Yellon D. Does ischemic preconditioning occur in patients?
J Am Coll Cardiol. 1994;24:11331142.
90. Yellon DM, Alkhulaifi AM, Pugsley WB. Preconditioning the human
myocardium. Lancet. 1993;342:276 277.
91. Dana A, Sumeray MS, Yellon DM. Ischaemic preconditioning: a clinical
perspective. Hosp Med. 1998;59:216 220.
92. Walker DM, Walker JM, Pugsley WB, et al. Preconditioning in isolated
superfused human muscle. J Mol Cell Cardiol. 1995;27:1349 1357.
93. Speechly-Dick ME, Grover GJ, Yellon DM. Does ischemic preconditioning in the human involve protein kinase C and the ATP-dependent
K channel? Studies of contractile function after simulated ischemia in
an atrial in vitro model. Circ Res. 1995;77:1030 1035.
94. Yellon DM, Dana A. The preconditioning phenomenon: a tool for the
scientist or a clinical reality? Circ Res. 2000;87:543550.
95. Deutsch E, Berger M, Kussmaul WG, et al. Adaptation to ischemia
during percutaneous transluminal coronary angioplasty: clinical, hemodynamic, and metabolic features. Circulation. 1990;82:2044 2051.
96. Lessar MA, Stoddard M, Almed M, et al. Preconditioning of human
myocardium with adenosine during coronary angioplasty. Circulation.
1997;95:2500 2507.
97. Saito S, Mizumura T, Takayama T, et al. Anti-ischemic effects of
nicorandil during coronary angioplasty in humans. Cardiovasc Drugs
Ther. 1995;9:257263.
98. Tomai F, Crea F, Gaspardone A, et al. Ischemic preconditioning during
coronary angioplasty is prevented by glibenclamide, a selective ATPsensitive K channel blocker. Circulation. 1994;90:700 705.
99. Kloner RA, Shook T, Przyklenk K, et al. Previous angina alters
in-hospital outcome in TIMI 4: a clinical correlate to preconditioning?
Circulation. 1995;91:37 45.
100. Anzai T, Yoshikawa T, Asakura Y, et al. Preinfarction angina as a major
predictor of left ventricular function and long-term prognosis after a first
Q wave myocardial infarction. J Am Coll Cardiol. 1995;26:319 327.

Consequences of Brief Ischemia

3167

101. Ottani F, Galvani M, Ferrini D, et al. Prodromal angina limits infarct

size: a role for ischemic preconditioning. Circulation. 1995;91:291297.
102. Ishihara M, Sato H, Tateishi H, et al. Implication of prodromal angina
pectoris in anterior wall acute myocardial infarction: acute angiographic
findings and long-term prognosis. J Am Coll Cardiol. 1997;30:970 975.
103. Kloner RA, Shook T, Antman EM, et al, and the TIMI-9B Investigators.
Prospective temporal analysis of the onset of preinfarction angina versus
outcome. Circulation. 1998;97:10421045.
104. Andreotti F, Pasceri V, Hackett DR, et al. Preinfarction angina as a
predictor of more rapid coronary thrombolysis in patients with acute
myocardial infarction. N Engl J Med. 1996;334:712.
105. Zahn R, Schiele R, Schneider S, et al, for the Myocardial Infarction
Registry Study Group. Effect of preinfarction angina pectoris on
outcome in patients with acute myocardial infarction treated with
primary angioplasty (results from the Myocardial Infarction Registry
[MIR]). Am J Cardiol. 2001;87:1 6.
106. Kloner RA, Przyklenk K, Shook T, et al. Protection conferred by
preinfarct angina is manifest in the aged heart: evidence from the TIMI
4 Trial. J Thromb Thrombolysis. 1998;6:89 92.
107. Jimenez-Navarro M, Gomez-Doblas JJ, Alonso-Briales J, et al. Does
angina the week before protect against first myocardial infarction in
elderly patients? Am J Cardiol. 2001;87:1115.
108. Abete P, Ferrara N, Cacciatore F, et al. Angina-induced protection
against myocardial infarction in adult and elderly patients: a loss of
preconditioning mechanism in the aging heart? J Am Coll Cardiol.
1997;30:947954.
109. Abete P, Ferrara N, Cioppa A, et al. Preconditioning does not prevent
postischemic dysfunction in aging heart. J Am Coll Cardiol. 1996;27:
17771786.
110. Okazaki Y, Kodama K, Sato H, et al. Attenuation of increased regional
myocardial oxygen consumption during exercise as a major cause of
warm-up phenomenon. J Am Coll Cardiol. 1993;21:15971604.
111. Williams DO, Bass TA, Gerwitz H, et al. Adaptation to the stress of
tachycardia in patients with coronary artery disease: insight into the
mechanism of the warm-up phenomenon. Circulation. 1985;71:
687 692.
112. Tomai F. Exercise-induced myocardial ischemia triggers early phase of
preconditioning but not the late phase. Am J Cardiol. 1999;83:586 588.
113. Dana A, Yellon DM. ATP dependent K channel: a novel therapeutic
target in unstable angina. Eur Heart J. 1999;20:25.
114. Mentzer RM, Rakko PS, Molina-Viamonte V, et al. Safety, tolerance,
and efficacy of adenosine as an additive to blood cardioplegia in humans
during coronary artery bypass surgery. Am J Cardiol. 1997;79:38 43.
115. Mahaffey KW, Puma JA, Barbagelata A, et al. Results of multicenter,
randomized, placebo controlled trial: the acute myocardial infarction
study of adenosine (AMISTAD) Trial. J Am Coll Cardiol. 1999;34:
17111720.

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