The myocardial sodium-hydrogen exchanger (NHE) and its role in mediating ischemic and reperfusion injury.

A major mechanism by which the heart adapts to intracellular acidosis during ischemia and recovers from the acidosis after reperfusion is through the sodium-hydrogen exchanger (NHE). There are at least 5 NHE isoforms thus-far identified with the NHE-1 subtype representing the major one found in the mammalian myocardium. This 110 kDa glycoprotein extrudes protons concomitantly with Na influx in a 1:1 stoichiometric relationship rendering the process electroneutral. Although NHE is critical for the maintenance of intracellular pH during acid loading conditions such as ischemia, there is convincing evidence that it also plays a pivotal role in mediating tissue injury during ischemia and reperfusion. The mechanism for this paradoxical deleterious role of NHE reflects the fact that under conditions of tissue stress, including ischemia, Na-K adenosine triphosphate (ATP)ase is inhibited thereby limiting Na extrusion resulting in an elevation in intracellular Na concentrations. The latter effect, in turn, will increase intracellular Ca concentrations via Na-Ca exchange. In addition, NHE-1 expression in the diseased myocardium is increased suggesting that elevated production of the antiporter represents a long-term adaptive process in an attempt by the cardiac cell to regulate intracellular pH which, paradoxically, contributes to cardiac pathology. Extensive studies using NHE inhibitors such as amiloride or its analogs, or more specific compounds including 3-methylsulphonyl-4-piperidinoloenzoyl-guanidine methanesulphonate (HOE 694) or 4-isopropyl-3-methylsulphonylbenzcyl-guanidine methane sulphonate (HOE 642) have consistently shown protective effects against ischemic and reperfusion injury in a large variety of experimental models and animal species particularly in terms of attenuating contractile dysfunction. Such studies have contributed greatly to the overwhelming evidence that NHE activation mediates ischemic and reperfusion injury. Indeed, HOE 642 (Cariporide) is currently undergoing clinical evaluation in high risk cardiac patients. Moreover, there is now emerging evidence that NHE may be involved in mediating cardiotoxicity directly produced by various ischemic metabolites such as lipid amphiphiles or reactive oxygen species. In this regard, we have demonstrated that NHE inhibitors can effectively attenuate the cardiac injury produced by lysophosphatidylcholine and hydrogen peroxide. In addition, it now appears that NHE inhibition reduces apoptosis in the ischemic myocardium, a process which may be of importance in the subsequent development of postinfarction heart failure. In conclusion, NHE represents an important adaptive process in response to intracellular acidosis resulting in a paradoxical contribution to cardiac tissue injury.