Combination of a Calcium Antagonist, a Lipid-Peroxidation Inhibitor, and an Angiotensin AT1-Receptor Antagonist Provides Additive Myocardial Infarct Size-Limiting Effect in Pigs

The calcium antagonist felodipine, the lipid-peroxidation inhibitor H290/51, and the angiotensin II type 1 (AT1)-receptor antagonist candesartan all exert beneficial effects on myocardial ischemia/reperfusion injury. This study was undertaken to test the hypothesis that a combination of these drugs with different pharmacologic properties could exert additive cardioprotective effects. Anesthetized pigs were subjected to 45 min of left anterior descending coronary artery occlusion followed by 240 min of reperfusion. Five groups of pigs were randomly given either 0.65 microM (7 nmol/kg) felodipine, 1.0 microM (3.1 microg/kg) H 290/51, 4.2 microM (20 microg/kg) candesartan, a cocktail of these three drugs, or vehicle (n = 6 for each) for 30 min starting at 5 min before reperfusion by coronary venous retroinfusion, which delivers drugs specifically to the ischemic regions. Systolic segment shortening (%SS) was measured by sonomicrometer. The myocardial area at risk and the final infarct size were determined by Evans blue and 2,3,5-triphenyl tetrazolium chloride staining. The hemodynamics did not change significantly during the study. In the vehicle group, the recovery of coronary flow was not maintained during reperfusion, and it was significantly lower after 240 min of reperfusion than during the preischemic period (p < 0.05). The coronary flow in the drug-treated groups was approximately the same by the end of the reperfusion period as that before the induction of ischemia. In the ischemic myocardium, %SS slightly recovered during reperfusion in the four drug-treated groups, but not in the vehicle group. The infarct size, expressed as a percentage of the myocardial area at risk, was smaller in all four drug-treated groups compared with the vehicle group. The infarct size in the cocktail group was significantly smaller than that in the groups given felodipine, H290/51, or candesartan alone. These results demonstrate that a combination of a calcium antagonist, a lipid-peroxidation inhibitor, and an angiotensin AT1-receptor antagonist has an additive effect on infarct limitation, indicating that combined therapy with agents having different pharmacologic modes of action may provide better cardioprotection than any of the drugs alone. The findings also support the view that reperfusion injury is possibly mediated by a combination of mechanisms.