Heart Failure Clin 1 (2005) 171 181

The Failing Cardiomyocyte

Sian E. Harding, PhD*
National Heart and Lung Institute, London, UK

Heart failure is a syndrome that arises primarily

from a loss of power of the contracting muscle of
the heart. Genetic studies have shown that some
idiopathic dilated cardiomyopathies are caused by
a defect in the individual muscle units of the heart
(cardiomyocytes), such as a mutation in the proteins
of the sarcomere, which leads directly to poor contractility [1]. Most heart failure is a result of a
mismatch between power output and demand, however, either because of cardiomyocyte loss (myocardial infarction, chemical agents) or increased load
(hypertension, valve disease). The key question has
been whether the contractility of cardiomyocytes in
this group of acquired (rather than genetic) cardiomyopathies is normal, or whether the continued
stress has produced secondary changes. The answer
seems to be that the function of the cardiomyocyte
in the failing human heart deteriorates with time. Not
only are fewer cardiomyocytes attempting to support
the same load, but their ability to contract is impaired
progressively. With continued cell loss (see article by
Grazette and colleagues elsewhere in this issue), this
leads to the cycle of decline that characterizes the
etiology of heart failure.
This article describes the changes in function that
are observed in the cardiomyocyte from the failing
human heart. In many cases, the alterations are
remarkably similar whether the originating cause of
the condition was cell loss or increased load. Even
when there is a known mutation, secondary alterations will decrease contractility further. It has been

* National Heart and Lung Institute, Faculty of Medicine, Imperial College London, Dovehouse Street, London
SW3 6LY, UK.
E-mail address: sian.harding@imperial.ac.uk

hypothesized that the mechanisms that are activated

to support the remaining function of the damaged
heart, such as the renin-angiotensin and sympathetic
nervous systems, contribute to the deterioration of
function. The author includes evidence that this is
the case for each of the changes observed. Much
information has been gained from the reversal of
heart failure induced changes after prolonged support by ventricular assist devices, and the relation
between recovery of the ventricle and reversal of
these alterations is discussed. Similarly, the changes
in function following mutations of individual proteins have given insights into the role of these proteins in heart failure.

Reduced contraction
The first main functional change seen in the failing cardiomyocyte is reduced contraction, which is
more pronounced at higher stimulation frequencies.
Muscle strips from failing human heart show a reduced force of contraction compared with nonfailing heart. As stimulation frequency (beating rate)
increases in the physiologic range, the force of contraction of nonfailing human myocardium increases
(the Bowditch or Treppe effect). In failing ventricle
this effect is reduced or lost completely, which contributes to the inability of the heart to respond to
exercise [2 4]. When intact muscle is studied, however, it is not possible to distinguish the effects of
cardiomyocyte loss or damage from those of reduced
contraction of individual cells. Cardiomyocytes therefore have been isolated from human myocardium by
enzymatic digestion and single-cell contraction has
been measured. Contraction of cardiomyocytes can
be quantified either as the extent of shortening of

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harding

isolated unloaded cells or as the amount of force that

is generated by loaded ones. Because mechanical
loading of single cardiomyocytes while preserving
the integrity of the sarcolemma is technically difficult, most evidence comes from cell-shortening
studies. Loss of the frequency response is observed
in ventricular cardiomyocytes from failing human
heart, showing that this phenomenon originates at the
level of the muscle cell [5].
Depressed contraction at higher stimulation frequencies is common to several etiologies, including
ischemic and idiopathic dilated cardiomyopathies
and mitral valve disease [5]. It is therefore likely to
be secondary to the main disease process, and occur
as part of the adaptation of the body to the failing
heart [6]. Animal models to test this hypothesis have
been hampered by the fact that the most commonly
used species, rat and mouse, do not have a positive
frequency response in normal muscle (at least at over

the lower frequency range) [7]. Rabbit and guinea-pig

myocytes do show this phenomenon, and a depressed
frequency response was shown in a rabbit model of
pacing-induced heart failure [8]. Sympathetic nervous
system (SNS) activation may be the trigger; infusion
of catecholamines into guinea pigs produced a
depression of the frequency-response curve despite
an absence of overt heart failure [9].
The mechanism of the reduction in positive
frequency response in failing human heart is related
to changes in Ca2+ handling by the cardiomyocyte. In
normal heart, Ca2+ entry through the L-type Ca2+
channel triggers further release from Ca2+ stores in
the sarcoplasmic reticulum (SR) through a second
Ca2+ channel in the SR membrane (Fig. 1). Ca2+ in
the cytoplasm binds to the troponin/tropomyosin
complex and activates the contraction of the myofilaments. During diastole, Ca2+ either is removed from
the cell entirely, primarily through a Na+/Ca2+

Fig. 1. b-adrenoceptor control of calcium handling in the cardiac myocyte. Solid lines represent pathways of cyclic AMP
stimulation, and dashed lines are pathways that reduce the amount or effects of cyclic AMP. AC, adenylyl cyclase; AKAP,
A-kinase anchoring protein; b1AR, b1-adrenoceptor; b2AR, b2-adrenoceptor; Gi, inhibitory guanine nucleotide binding protein;
Gs, stimulatory guanine nucleotide binding protein; Ikx, repolarising K+ channels; NCX, Na+/Ca2+-exchanger; PKA, cyclic
AMP dependent protein kinase, or protein kinase A; Plb, phospholamban; Plmn, phospholemman; PP1, protein phosphatase 1;
PP1-I, PP1-inhibitor; RyR, sarcoplasmic reticulum Ca2+ release channel; SERCA2a, SR Ca2+-ATPase; TnI,C,T, toponins I, C,
and T; TM, tropomyosin. (Courtesy of Simon Wooltorton, BSc, London, UK.)

failing cardiomyocyte

exchange mechanism at the sarcolemma, or taken up

again into the SR stores by an energy-dependent
pump, the SR Ca2+-ATPase (SERCA2a in heart) [10].
Loss of contractile power can be caused either by the
amount of activating Ca2+ (the Ca2+ transient) or the
sensitivity of the myofilaments to Ca2+. In failing
human myocardium, myofilament sensitivity of Ca2+
is increased [11], whereas the Ca2+ transient is depressed and prolonged [12,13]. Ca2+ supply to the
myofilaments is therefore the underlying cause of the
contractile deficit.
Concerted changes occur in several of the key
Ca2+ handling proteins in the failing myocardium,
and their interdependence has made it difficult to
isolate the role of any single element, but some
general conclusions have emerged. Firstly, Ca2+ entry
is probably normal, and may be increased [14].
Various reports have described the L-type Ca2+
channels as normal or impaired [15,16], but they
may be activated by phosphorylation or remain in
the open state longer because of the prolongation
of the action potential plateau [17]. Secondly, Ca2+
stores in the SR are decreased during steady state
beating. This has been shown by release of Ca2+ from
the SR using caffeine or rapid cooling [18,19].
Several changes contribute to this effect. SERCA2a activity is decreased, in some cases as a result
of a decrease in SERCA2a expression [20,21]. Most
reports, however, show SERCA2a activity decreased
to a greater extent than protein concentration [22,23].
Ca2+ uptake activity is determined by the ratio of
SERCA2a to its inhibitory protein, phospholamban,
and this in turn is modulated by the ratio of
phosphorylated to nonphosphorylated phospholamban. The decrease in SERCA2a protein/activity
correlates with the functional loss of the frequency
response [21,24]. Pharmacologic inhibition of SERCA2a activity will mimic in normal human myocytes
the poor frequency response seen in failing cells [25].
Conversely, overexpression of SERCA2a protein
using adenoviral vectors can restore the frequency
response in cardiomyocytes from failing human
heart [26].
A synergistic effect also may be produced by the
increase of the Na+/Ca2+-exchanger (NCX). NCX
protein levels are raised in some patients, although
reports are not as consistent as those for the
SERCA2a decrease [27,28]. Overexpression of
NCX in rat or rabbit cardiomyocytes produces a
decrease in contraction because of reduction in SR
Ca2+ stores [29 31]. This can be overcome by increasing stimulation frequency at low but not high
overexpression levels [29,30]. It is likely that the
SERCA2a and NCX compete for Ca2+ in diastole and

173

that increased NCX extrudes more cytoplasmic Ca2+

before it can be stored. There may be preferential
localization of NCX close to the sites of Ca2+ entry to
favor this extrusion [32], but the final effect of NCX
depends critically on the level of Na+ within the
cardiomyocyte. In transgenic mouse cardiomyocytes,
in contrast to rat and rabbit, overexpression of NCX
produces increased SR Ca2+ storage [33]. This may
be a result of the high average levels of Na+ in the
mouse [34], causing the NCX to run in Ca2+ entry
mode for a greater part of the cardiac cycle.
Na+ levels have been difficult to measure in human myocardium, but direct and indirect evidence
favors an increase in Na+ in the failing human heart
[35,36]. This would be consistent with the loss of
Na+/K+ ATPase protein and alteration in a-subunit
isoforms in failing human myocardium [28], although
there may be compensatory mechanisms that preserve
Na+/K+ ATPase activity in animal models [37]. The
final consequence of the NCX upregulation on contractile force in failing human heart therefore remains
undetermined, with evidence to suggest that Ca entry
by reverse mode NCX may support the Ca2+ transient
[38]. A third contributor to the loss of SR Ca2+ stores
is the SR Ca2+ release channel, also known as the
ryanodine receptor (RyR). This protein is a large
macromolecular assembly containing both channels
and associated components. There is evidence
(although conflicting) that dissociation of one of
these components, termed FKBP12.6, produces a
leak of Ca2+ from the RyR in heart failure and thus
further reduces stored Ca2+ [39,40]. Overexpression
of FKBP12.6 increases Ca2+ stores in isolated cardiomyocytes [41].
In patients who have received left ventricular
assist device (LVAD) support, the force-frequency
response is restored toward normal, but there is
variability in this recovery [42]. SR Ca2+ stores
clearly play a major role in heart failure because
patients whose Ca2+ stores were normalized were
more likely to have restored cardiac function than
those whose stores remained low [43].

Impaired relaxation that contributes to diastolic

dysfunction
The second main functional change seen in the
failing cardiomyocyte is impaired relaxation that contributes to diastolic dysfunction. Duration of contraction (measured as time to maximum shortening)
and relaxation (time to 50% or 90% relengthening)
is increased in the cardiomyocyte from the failing
human ventricle. Again, this is a common alteration,

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independent of disease etiology, but there is also a

statistical element related to increasing age of the
patient [44]. It is associated frequently with hypertrophic models of disease and increased myocyte
size. The enlargement of cardiomyocytes that accompanies heart failure in human does not influence cell
relaxation [44], however, and the deficit is related
primarily to changes in the Ca2+ transient [13].
Increased sensitivity of the myofilaments also may
contribute to some extent, because of the decrease
in Ca2+ dissociation rate. As with the frequency
response, changes in Ca2+ movement underlie the
alteration in the Ca2+ transient. The action potential is
prolonged because of a decrease in repolarizing
currents (see later discussion), and this extends the
time of Ca2+ entry. The Ca2+ transient is not only
longer, but can fail to return completely to initial
values when the stimulation frequency is increased.
Diastolic Ca2+ therefore rises, and relaxation is
impaired [45,46]. At the levels of the whole heart
this can play a part in diastolic dysfunction, together
with changes in wall thickness and fibrosis.
Delayed uptake into the SR, secondary to the
reduced SERCA2a activity, is the prime cause of the
slow decrease in diastolic Ca2+. As before, inhibition
of SERCA2a mimics the slow relaxation seen in
failing human heart whereas overexpression of
SERCA2a reverses it [25,26]. LVAD support restores
relaxation parameters as well as those of contraction [16]. Ca2+ leak through the RyR may contribute
to SR Ca loss and especially to the inability of Ca2+
uptake to return diastolic Ca2+ to basal levels. The
increase in NCX theoretically should alleviate the
slow rate of Ca2+ removal by accelerating Ca2+ extrusion from the cardiomyocyte. Patients with increased NCX as well as SERCA2a loss had improved
diastolic function compared with those with SERCA2a loss alone [47]. Improved diastolic Ca removal,
however, has not been demonstrated in NCX overexpression studies where relaxation and decay of
the Ca transient are prolonged slightly [30].

Arrhythmias more likely

The third main functional change seen in the
failing cardiomyocyte is the greater likelihood of arrhythmias. The failing heart is clearly an arrhythmic
substrate, with thickening of the ventricular walls,
myocyte death, and replacement fibrosis providing a
heterogeneous pathway for the electrical impulse and
increasing the likelihood of reentrant circuits. Electrical remodeling is well characterized in the failing
human cardiomyocyte. Changes are largely in repo-

larization currents, with expression of IK1 (the inward

rectifier) and Iks/IKr (delayed rectifier) decreased and
Ito (transient outward current) reduced in a gradient
across the ventricular wall [48 52]. These changes
underlie the increase in action potential duration, and
may be exacerbated by loss of the hyperpolarizing
influence as Na+/K+-ATPase decreases. It is also
possible that reduction in SERCA2a activity contributes to the effect because overexpression of
SERCA2a decreases action potential duration [53].
Parallels with prolonged repolarization caused by
genetic changes in K channels have led to the heart
failure phenotype being described as acquired long
QT syndrome. The heterogeneity of channel alterations can contribute to the arrhythmogenicity of
the myocardium as a whole, but the changes also
predispose to arrhythmic episodes at the level of
the cardiomyocytes.
Cellular arrhythmias have been divided into two
main classes: early and delayed afterdepolarizations.
Early afterdepolarizations occur before full repolarization has taken place, during the plateau of the
action potential. One hypothesis is that the prolongation of the action potential allows time for the L-type
Ca channels to recover from their natural refractory
period and become reactivated [54]. Depending on
the amount of Ca2+ flux through the channels, either a
further slowing of Ca2+ removal (and relaxation) or a
distinct aftercontraction is observed. Aftercontractions can be abolished selectively in human cardiomyocytes by shortening the action potential duration,
with IkATP channel openers, for example [55].
Delayed afterdepolarizations occur after full repolarization has occurred, and may result in ectopic
beats. These are a result of spontaneous Ca2+ release
from the SR, and the membrane current is produced
by electrogenic NCX [56]. Loss of IK1 also will mean
that a given SR Ca2+ release is more likely to trigger a
delayed afterdepolarization [56]. Spontaneous SR
Ca2+ release in the failing human heart is unlikely
to be caused by excess SR Ca because the stores are
depleted. It is more probable that raised cytoplasmic
Ca or a change in sensitivity increases the likelihood
of RyR opening in the diastolic period. The fact that
SERCA2a overexpression, which increases SR Ca2+
but decreases cytoplasmic Ca2+, is antiarrhythmic in
human cardiomyocytes, animal cardiomyocytes,
and animal models of heart failure in vivo would
support this hypothesis [57 59]. Comparison with
genetic causes of arrhythmia is instructive: a class of
catecholamine-stimulated ventricular tachycardias is
caused by a mutation in the RyR that leads to increased diastolic leak and increased sensitivity of the
RyR to the trigger Ca [60].

failing cardiomyocyte

Reduced B-adrenoceptor responses

The fourth main functional change seen in the
failing cardiomyocyte is reduced b-adrenoceptor
(bAR) response. The endogenous catecholamines,
epinephrine and norepinephrine, increase the rate and
force of contraction of the heart and accelerate relaxation. The loss of responsiveness to either endogenous or exogenous catecholamines is a hallmark of
heart failure. Although reduced catecholamine release
contributes to the effect [61], functional bAR desensitization is seen at the level of the isolated atrial or
ventricular cardiomyocyte from failing human heart
[62,63]. Cellular bAR desensitization is seen in various etiologies of heart failure, although there is a
strong independent contribution of increasing age of
the patient [62]. It clearly is related to prolonged high
sympathetic drive, and can be mimicked by infusion
of catecholamines into animal models [64 66].
Again, LVAD support will restore bAR responsiveness to the failing cardiomyocyte [67].
With the reduction of sensitivity to SNS stimulation, the heart has lost the other main process that,
with the force-frequency response, allows an increase
in output during exercise. Briefly, b1-adrenoceptors
(b1AR) are lost; b2-adrenoceptors (b2AR) and stimulatory guanine nucleotide binding proteins (Gs) are
maintained; inhibitory guanine nucleotide binding
protein (Gi) and bAR kinase (bARK) levels are increased; and b-arrestin is translocated to the membrane [68]. This has consequences for cell loss:
downregulation of the b1ARs may curb their apoptotic effects on the myocardium [69]. There are also
consequences for excitation-contraction coupling
over and above that caused by loss of peak bAR
response that will be considered here.
Human cardiac ventricle has a higher ratio of
b2AR to b1ARs (30:70) than most mammalian
species, which increases in heart failure because
of the selective downregulation of the b1AR [70].
The two receptor subtypes coexist on the same ventricular myocyte [71], and both can increase force
and accelerate relaxation through the Gs/adenylate
cyclase/cyclic AMP system [72]. Cyclic AMP
(cAMP) dissociates the regulatory from the catalytic
subunits of cAMP-dependent protein kinase (PKA),
allowing phosphorylation of several substrates within
the cardiomyocyte (see Fig. 1). The b1AR usually
acts entirely through Gs, but an additional action of
the b2AR to activate simultaneously Gs- and Gicoupled pathways has been demonstrated in animal
and human hearts [73,74]. Activation of Gi will
reduce cAMP production and alter the range of
targets for PKA phosphorylation [75].

175

Other mechanisms also reduce PKA-dependent

phosphorylation. Protein phosphatases limit the effect
of cAMP-dependent phosphorylation by dephosphorylating the target proteins. The activity of one of
the main isoforms in the cardiomyocyte, protein
phosphatase 1 (PP1), is limited by a natural inhibitor,
PP1-inhibitor (PP1-I). In the failing human cardiomyocyte, PP1 levels are increased [76] and PP1-I is
reduced [77], with PP1-I activity further inhibited by
a phosphorylation through protein kinase C [78] and
a lack of phosphorylation by PKA [79]. Phosphatase
activity therefore is increased. The concerted effect in
the failing cardiomyocyte is a decrease in cAMPdependent phosphorylation in the presence and absence of a bAR stimulus. Tonic withdrawal of PKA
phosphorylation contributes to the changes in contraction and relaxation but, ironically, it is the residual
effects of catecholamines that contribute to arrhythmia genesis in the failing cardiomyocyte.
Key PKA substrates for excitation-contraction
coupling are the Iks, the L-type Ca channel,
phospholamban, troponin I, and the RyR. Phospholamban is the inhibitory protein controlling the
activity of SERCA2a.
Phosphorylation of phospholamban occurs at two
sites: serine 16, mediated by PKA, and threonine 17,
mediated by calcium/calmodulin-activated protein
kinase (CaMKII) [80]. In each case, phosphorylation
reduces the inhibitory effect of phospholamban on
SERCA2a. In the failing cardiomyocyte there are varying reports of the actual amount of phospholamban
or its concentration relative to SERCA2a. What seems
to be more important is the phosphorylation state,
particularly the PKA-dependent phosphorylation.
In human heart failure and many animal models
there is hypophosphorylation of phospholamban,
detected either through back-phosphorylation (where
the amount of radioactive phosphate required to
fill empty sites on the protein is determined) or by
Western blot using antibodies specific for the
phosphorylated forms of phospholamban [22,81].
Reduced phosphorylation increases the tonic inhibitory effects of phospholamban on SERCA2a and
contributes to the decrease in SR uptake of Ca2+. The
discrepancy between consistent reduction in SERCA2a activity and the varying reports on SERCA2a
protein levels may be explained by the contribution
of dephosphorylated phospholamban [81].
Phospholamban removal can restore significantly
the function of the failing cardiomyocyte. Downregulation of phospholamban using antisense adenoviral vectors has equivalent effects to overexpression
of SERCA2a in animal myocytes and those from
failing human ventricle [26,57,82]. Even stimulation

176

harding

of isolated ventricular cardiomyocytes from human

heart with isoproterenol, despite desensitization of the
bAR response, produces sufficient phosphorylation to
normalize early relaxation velocities [83]. Troponin I,
like phospholamban, is hypophosphorylated at the
PKA site in the failing cardiomyocyte [11]. This
results in the increased Ca2+ sensitivity of the myofilaments and therefore a tendency toward slower
relaxation and increased residual force during diastole. Like phospholamban, bAR stimulation would
restore the characteristics of troponin I toward those
in the nonfailing heart.
If phosphorylation of phospholamban and troponin I through the bAR/cAMP/PKA system could
normalize early relaxation in the failing human heart,
why are catecholamines and phosphodiesterase inhibitors not a successful treatment for heart failure?
Apart from the long-term apoptotic effects, acute
bAR stimulation has an increased tendency to produce arrhythmias in the failing cardiomyocyte, and
sufficient residual capacity exists in the bAR system
for this to be a factor in sudden death. Several factors
contribute to this effect.
First, there is residual phosphorylation of the RyR
in failing heart above that seen in nonfailing heart. It
has been termed hyperphosphorylation to distinguish
it from the decreased phosphorylation (hypophosphorylation) seen for phospholamban and troponin I
[39]. This may be the result of different spatial
domains occupied by PKA, phosphodiesterases, and
phosphatases relative to RyR or phospholamban.
Such domains, or signalosomes, assembled by
anchoring proteins such as PKA anchoring protein
(AKAP), are described increasingly [84,85]. The
extent of RyR phosphorylation and its effect on Ca
release are controversial: experimental differences
may occur depending on whether the tissue is snapfrozen (and therefore represents the heart under
sympathetic drive) or washed (where it will return
to the basal, unstimulated state). It may be that
phosphorylation is more efficient at the RyR, so that
even under conditions of bAR desensitization there
is sufficient PKA activity to maintain RyR phosphorylation above basal. The result of hyperphosphorylation is to increase the open probability of
the RyR, and possibly to produce a diastolic leak
through the dissociation of the accessory protein,
FKBP12.6 [39]. This would contribute to the poor
diastolic relaxation and increased probability of
spontaneous Ca release described above. If the
proarrhythmic changes in RyR are caused by PKAdependent phosphorylation, then any further stimulation of the bAR will exacerbate this effect. It is
instructive to note that several genetic RyR mutations

produce arrhythmic changes, mainly in the presence

of catecholamines [60].
Second, the loss of Iks means that isoproterenol
stimulation has a different effect on action potential
duration in failing than nonfailing cardiomyocytes. In
the normal heart, bAR agonists shorten the action
potential, because stimulation of repolarization
through Iks outweighs the prolongation produced
by activation of the L-type Ca channel [86]. In the
failing cardiomyocyte, the overall effect of sympathetic stimulation is an exacerbation of the increased
action potential prolongation [87,88]. Inhibition of
IK1 by bAR agonists contributes to this effect [88].
Third, there is residual PKA-dependent phosphorylation of the L-type Ca channel above that in normal
cardiomyocytes, similar to that described for the RyR,
and this may maintain Ca2+ entry in the face of reduced channel density [89]. Increased open probability of the L-type Ca channels will increase the
likelihood of reopening during the action potential
plateau. The changes in the L-type Ca channel will
act synergistically with the lengthening of action
potential duration to increase the probability of early
afterdepolarizations. The distinction between the
beneficial effects of selected phospholamban phosphorylation and the deleterious consequences of the
concerted bAR response is caused therefore by the
additional effects of the bAR on the RyR, L-type Ca
channel, and IK currents. This explains the strong
divergence between the results of phospholamban
knockout or removal and those of bAR activation/
overexpression on cardiomyocytes from failing human heart [57] or in animal models [59,90].
bAR control extends to other systems that are
involved excitation-contraction coupling and are
altered in the failing cardiomyocyte, but whose effects are less well defined. Na+/K+-ATPase activity
was reported to be inhibited by PKA-dependent
phosphorylation [91], but recent evidence suggests
that the accessory protein phospholemman is also a
PKA substrate, and that ischemia-dependent activation of Na+/K+-ATPase is a result of phosphorylation
at the PKA site of phospholemman [92]. Phospholemman may act in an analogous manner on the Na+/
K+-ATPase to phospholamban on SERCA2a, producing an inhibition that is relieved by phosphorylation [92]. bAR stimulation could offset the decrease
in activity caused by Na+/K+-ATPase downregulation. If PKA-dependent phosphorylation is reduced
in the failing cardiomyocyte, however, then Na+/K+ATPase activity would be decreased further, potentially adding to the rise in intracellular Na+. NCX also
can be phosphorylated by PKA, and its activity increased [93].

failing cardiomyocyte

It is unknown how the steady-state balance of

phosphorylation of NCX would affect its observed
activity in the failing cardiomyocyte. If the raised
NCX levels are preserving diastolic function, then
reduction of activity as cAMP decreases would be
predicted to be deleterious. The interaction between
residual bAR stimulation and raised NCX has been
postulated to increase the likelihood of delayed afterdepolarizations in a rabbit model of failure [94].
There also may be a link between NCX and the
b2AR, independent of cAMP/PKA. Overexpression
of NCX in rat cardiomyocytes strongly depressed the
concentration response curve to isoproterenol, the
nonselective b1- and b2AR agonist [95]. Inhibition of
the b2AR or Gi revealed a normal response through
the b1ARs, showing that b2AR-Gi coupling is
responsible for the loss of bAR effect. The author
has suggested that b2AR-Gi somehow is activating
the NCX to produce a negative inotropic effect that
suppressed the positive response through Gs/cAMP.
If NCX and Gi are raised in the failing human heart,
and the b2AR:b1AR is increased, then some of the
loss of bAR response may be a result of b2AR-GiNCX coupling.

Overview: role of B-adrenoceptor response in the

phenotype of the failing cardiomyocyte
Taking each of the main changes in the failing
cardiomyocyte in turn, the loss of bAR function interacts with alterations in cellular protein levels in a
complex manner. To produce a complete picture, one
should consider each of three situations: the failing
cardiomyocyte (1) without tonic bAR stimulation, (2)
under theoretical maximum bAR stimulation, and (3)
as in failing human heart (residual but reduced bAR
stimulation and a switch from Gs to Gi coupling).
Under basal conditions, contraction amplitude is
not dependent on cAMP in either the normal or
failing human ventricular myocyte at low stimulation frequencies [96]. The loss of positive inotropic
response to increased rate depends on SR Ca2+ stores,
which are reduced because of the decreased SERCA2a:NCX ratio. Relaxation is prolonged because
of low SERCA2a activity and the long action potentials, and early afterdepolarizations may be seen.
Na+ is high, and diastolic Ca2+ also is increased.
Spontaneous release from the SR is rare (evidenced
by the lack of Ca2+ spark events in failing human
cardiomyocytes [97]), however, because SR stores
are low.
Maximum stimulation of the bAR partially reverses the loss of SERCA2a activity, and therefore

177

can increase the frequency response and accelerate

early relaxation. Increased Ca2+ entry through the
L-type Ca channel also increases contraction but,
together with further lengthening of action potential
duration, exacerbates early aftercontractions. Diastolic Ca2+ increases further because of increased
SR Ca2+ leak, and this plus the increased stores raises
the likelihood of spontaneous Ca2+ release. This
is more likely to produce a membrane current and
therefore a propagated action potential because NCX
protein levels are high, and activity is increased by
PKA-dependent phosphorylation.
In the failing human cardiomyocyte the bAR is
desensitized, and may be linked more strongly to Gi,
but few cells have lost completely the ability to
respond to isoproterenol. The total amount of cAMP
produced within the myocyte is reduced, which may
prevent some of the more deleterious effects of bAR
activation on arrhythmia generation. The offsetting
effect of phospholamban and troponin I phosphorylation also is reduced, however, so that maximum
contraction amplitude and early relaxation are poor,
closer to the effects observed in the basal state.
Exactly how close will depend on the severity and
duration of heart failure. There is residual support
from the SNS even in severe disease because of
the decrease in cardiac output during titration of
b-blockers [98]. Complete withdrawal of catecholamine exposure, as with moxonidine, has increased
mortality in patients who have heart failure [99].

Summary
The intimate connection between protein changes
in heart failure and those in the bAR system accounts
for the strong correlation between sympathetic
activation and mortality. This examination of the
interplay of the two systems makes clear why pump
failure and arrhythmia are increased in concert with
sympathetic activation and, conversely, decrease together after b-blocker therapy has allowed recovery
of the bAR signaling cascade.

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