World Journal of Cardiovascular Diseases, 2013, 3, 371-376 WJCD Published Online August 2013 (
Endothelin A-receptors and the coronary circulation
Evangelos Polymeropoulos1, Mesele Valenti1, Zenon S. Kyriakides1,2*
12nd Department of Cardiology, Hellenic Red Cross General Hospital, Athens, Greece
2Cardiovascular Research Institute, Athens, Greece
Email: *
Received 3 June 2013; revised 3 July 2013; accepted 20 July 2013
Copyright © 2013 Evangelos Polymeropoulos et al. This is an open access article distributed under the Creative Commons Attribu-
tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
We review the role of endothelin (ET) A-receptors (R)
on the coronary circulation. ET-1 maintains the nor-
mal coronary artery tone. ET-1 plasma levels are in-
creased during and after coronary angioplasty and
this increase is related to myocardial ischaemia rather
than to mechanical artery injury. ETAR antagonists
inhibit coronary artery vasoconstriction induced by
ET release after coronary angioplasty in humans. ET
promotes neointimal formation and ETAR antago-
nism has been shown to inhibit restenosis after angio-
plasty in the animal model but not in humans. ETAR
blockade increases coronary blood flow, dilates distal
coronary arterial segments and decreases coronary
vascular resistance. Coronary collaterals are less sen-
sitive than other coronary vessels to ET-1. ETAR bloc-
kade decreases collateral blood flow and, consequent-
ly, perfusion of the ischemic myocardium.
Keywords: Endothelin; Coronary Circulation
Diseases of the cardiovascular system account for the
majority of morbidity and mortality in Western countries.
Most forms of cardiovascular disease are associated with
impaired vascular function in the cerebral, coronary, re-
nal or peripheral circulation. Enhanced intermittent and/
or persistent vasoconstriction is one of the most impor-
tant features of several forms of cardiovascular disease.
An important local vascular regulator is the 21-amino
acid peptide endothelin (ET) with potent and characteris-
tically sustained vasoconstrictor and vasopressor actions
[1]. In the blood vessel wall, only endothelial cells pro-
duce the peptide and exclusively ET-1, except in disease
states such as atherosclerosis, where smooth muscle cells
may also contribute. Most of the ET-1 produced in the
endothelium interacts with vascular smooth muscles,
while only about one-third circulates and can be mea-
sured by ra dioimm un oas say techniques [2].
With intraluminal administration of ET-1, a transient
vasodilation due to activation of nitric oxide and prosta-
cyclin is observed followed by profound and sustained
vasoconstriction which is mediated by ETAR receptor
activation and at least in certain blood vessels also by
ETBR receptors [3,4]. With higher concentrations of ET-1,
only vasoconstriction is observed, although even then in-
hibition of a production of endothelium derived relaxing
factors enhances the response to the peptide [5].
Brunner [6] compared coronary and interstitial ET-1
levels in perfused rat hearts under several experimental
conditions. Basal ET-1 releasing into effluent was higher
than in transudate, but basal ET-1 concentration was
four-fold higher in transudate than in effluent. Following
the removal of the endothelial cells, ET-1 release in the
artery lumen decreased dramatically and was completely
abolished in interstitial transudate, indicating that the
peptide originated from the vascular endothelium [6].
When the coronary flow was reduced to an ischemic
level, ET-1 secretion rates into effluent decreased by
60%, but increased 3- to 4-fold after reperfusion at nor-
mal flow. These data do not support a vasoconstrictor
action of ET-1 in rats following ischemia/reperfusion,
but rather point to a possible vasodilator role of the pep-
tide under these conditions.
Thrombin and ischemia increase ET-1 production and
up-regulate its receptors. In patients with unstable angina,
increased staining for ET-1 can be demonstrated in
coronary artery lesions removed by atherectomy [7].
ET-1 levels were measured in blood samples, obtained
from the femoral vein of patients with stable angina, un-
dergoing coronary rotational atherectomy. Patients un-
dergoing plain balloon angioplasty were used as controls.
Plasma levels of ET-1 were higher in patients undergo-
ing balloon angioplasty, whereas in patients undergoing
*Corresponding a uthor.
E. Polymeropoulos et al. / World Journal of Cardiovascular Diseases 3 (2013) 371-376
atherectomy, these were only mildly elevated [8] (Figure
1). The peripheral release of ET-1 during angioplasty is
related to myocardial ischemia, rather than to endoth elial
injury [9] (Figure 2). Possible explanations for the
smaller ET-1 secretion during atherectomy compared
with balloon angioplasty are: 1) more calcified arteries
may secrete less ET-1 during ischemia; 2) more diffusely
diseased arteries may produce less ET-1 during ischemia,
and 3) the destruction of the endothelium during rota-
tional atherectomy is so extensive that it renders itself
unable to produce and excrete ET-1 into the plasma.
Tahara, et al. [10] reported that ET-1 is increased in
the coronary sinus after coronary angioplasty. ET-1 plas-
ma levels have been shown to increase more in normo-
tensive than in hypertensive patients after coronary an-
gioplasty [11]. Thus, ET-l has a weaker vasomotor effect
on the coronary vasculature in hypertensive patients than
in normotensives [12], due to reduced responsiveness to
ET-l by the small resistance arteries in the former. In
patients undergoing angioplasty, ET-1 is increased more
in patients with partially occluded coronary arteries than
in patients with totally occluded vessels. Thus, the in-
crease in ET-1 is another confirmation that ET-1 levels
are related to myocardial ischaemia rather than to me-
chanical artery injury [9].
Biopsies from internal mammary arteries in patients
undergoing coronary artery by-pass grafting showed that
systemic hypertension is associated with increased ET-1
and ETAR receptor mRNA expression, whereas insu-
lin-dependent diabetes down-regulates ETAR receptor
mRNA expression [13]. This could help explain the dif-
ferential response of hypertensive and diabetic animals
and humans to external and internal stimulation and
blockade of ET-1 and its receptors.
Figure 1. Plasma levels of Endotelin-1 were higher in patients
undergoing balloon angioplasty, whereas in patients undergoing
atherectomy, these were insignificantly raised. Letters A to E
denote the phases during which blood samples were drawn. A is
after the coronary artery engagement with the guiding catheter
(baseline), B is after the end of the rotational atherectomy, C is
after the first balloon inflation, D is immediately after the end
of the procedure, and E is 4 hours later [8].
Figure 2. Endothelin-1 during coronary angioplasty in a group
of patients with total (filled circles) and another with partial
(open circles) artery occlusion *<0.05 vs baseline. Letters A to
D denote the phases during which blood samples were drawn.
A is after the coronary artery engagement with the guiding ca-
theter (baseline), B is after the first balloon inflation, C is im-
mediately after the end of the procedure, and D is 4 hours later
In a study utilizing the selective ETAR antagonist
BQ-123 in patients undergoing angioplasty [14], acute
ETAR receptor antagonism prevented the normal reduce-
tion of myocardial ischemia on repeated balloon infla-
tions. This phenomenon may be explained by a “steal”
effect through coronary collaterals; local ETAR receptor
antagonism with BQ-123 causes coronary vasodilatation
(mainly at the distal coronary arterial segments), an in-
crease in coronary blood flow, and a decrease in the
coronary artery resistance [14] (Figure 3). ETAR recep-
tor antagonism may increase coronary blood flow and
decrease coronary artery resistance and distal coronary
pressure by dilating the distal arterial segments and the
resistance arteries in the non-ischemic region and in-
creasing coronary blood flow [15] (Figure 4).
Coronary vasoconstriction after coronary angioplasty
has been attributed to a variety of mechanisms and it can
be prevented by ETA receptor blockade. Quantitative
analysis of coronary angiography of the diameter of the
distal segment of coronary arteries 25 minutes after co-
ronary angioplasty, showed that intracoronary admini-
stration of BQ-123 hindered vasoconstriction of the dis-
tal segment [16] (Figure 5).
ET-1 and big ET-1 administration in rat hearts reduces
coronary blood flow. However, BQ-123, an ETAR recep-
tor antagonist abolishes the cardiac effect of ET-1 [17].
Cannan, et al. [18] showed that low concentrations of
exogenous ET-1 in dogs, which may mimic pathophysi-
ological concentrations, result in coronary vasoconstric-
tion mediated predominantly via the ETAR, since such
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E. Polymeropoulos et al. / World Journal of Cardiovascular Diseases 3 (2013) 371-376 373
Figure 3. Schematic representation of coronary arterial bed,
effects of myocardial ischemia, and possible effects of ETAR
antagonism (BQ-123). Coronary arteries can be divided into 2
functional components: large epicardial conductance arteries
and smaller resistance arterioles. After significant narrowing of
coronary artery, ischemic stimulus results in autoregulation of
small resistance vessels and consequently maximal vasodilation
in ischemic region. ETAR antagonism, in nonischemic region,
dilates distal arterial segments and resistance vessels, causing
decrease in coronary artery resistance, increase in blood flow,
and fall in distal coronary pressure. Fall in pressure at source of
collaterals may diminish collateral flow and perfusion of
ischemic myocardium. This deleterious effect is termed “coro-
nary steal” [14].
Figure 4. Coronary blood flow velocity in a patient with coro-
nary artery disease 15 minutes (top) and 30 minutes (middle)
after the initiation of BQ-123, an ETAR blocker, infusion and
after the end of the infusion (bottom). It can be seen that peak
velocity integral (PVI) increases from 14 to 17 and 22 cm, re-
spectively, while systolic blood pressure decreases from 162 to
154 and 151 mm Hg. Note that the blood flow velocity scale is
different in the three recordings [15].
Figure 5. Line plots of the diameter of the distal arterial seg-
ments at 5 and 25 minutes after completion of angioplasty with
BQ-123 (an ETAR antagonist) (right) or saline control admini-
stration (left). *: p < 0.05 versus 5-minute postangioplasty [16].
vasoconstriction is significantly attenuated by ETAR
blockade. Pernow, et al. [19] showed that intravenous
ET-1 administration decreases coronary sinus blood flow
and increases coronary vascular resistance in humans.
Endogenous ET-1 maintains the normal coronary ar-
tery tone and thus regulates coronary blood flow. In pa-
tients undergoing coronary arteriography, administra-
tion of intracoronary BQ-123 led to an increase in blood
flow in the left anterior descending coronary artery, an
increase in the diameter of the distal segment of the coro-
nary artery and a decrease in coronary vascular resis-
tance (Figure 4) [15]. Moreover, changes in blood flow
were similar in subjects with and without coronary artery
disease [15]. In coronary artery disease patients, coro-
nary artery compliance increased after intracoronary
BQ-123 [20]. ETAR dependent activity is impaired in
diabetic patients; coronary artery diameter in diabetic
patients increased far less in comparison to healthy sub-
jects after administration of intracoronary BQ-123 [21].
In a similar manner, physiologic response to ETAR
blockade was also attenuated in hypertensive patients
Collateral vessels demonstrate heightened sensitivity to
certain vasoconstrictors such as vasopressin, which can
decrease blood flow to the dependent myocardium at
doses that do not affect blood flow to normal myocar-
dium. Rapps, et al. [23] found that collateral vessel rings
constricted smaller-than-normal coronary arterial vessels
to ET-1. An impaired collateral vasoconstrictor response
might be expected to protect collateral blood flow when
ET-1 levels are increased. In the work of Traverse, et al.
[24], collateral blood flow did not significantly change
although coronary sinus ET-1 concentrations exceeded
70 pg/ml. Only at the highest infusion rate, when the
coronary blood concentration was 175 pg/ml, did colla-
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E. Polymeropoulos et al. / World Journal of Cardiovascular Diseases 3 (2013) 371-376
teral blood flow decrease significantly. It was demon-
strated that in the intact animal collateral vessels con-
strict similarly to normal vessels in response to ET-1.
Coronary collateral vessels can synthesise prostacyclin.
Furthermore, in dogs with long-term coronary occlusion,
prostacyclin appears to cause tonic collateral vessel dila-
tation [25] because cyclooxygenase blockade with indo-
methacin significantly decreased retrograde blood flow
from the cannulated collateral dependent artery. Traverse,
et al. [24] showed that prostacyclin production is impor-
tant in blunting th e vasoconstrictor effects of ET-1 in th e
collateral circulation. In contrast, the response of colla-
teral vascular resistance to ET-1 in the normal zone was
much less affected by inhibition of prostacyclin produc-
tion. This is in agreement with previous findings that
vasodilator prostaglandins are of greater importance in
collateral than in normal coronary vessels.
Well-developed collateral vessels exhibit nitric oxide-
mediated, endothelium-dependent vasodilation in res-
ponse to agonists such as acetylcholine or bradykinin
[26-28]. However, there are indications that vasodila-
tation of collateral vessels resulting from ET-1-stimu-
lated production of nitric oxide could also improve per-
fusion of the collateral-dependent region. ET-1 could al-
ter blood flow to the collateral-dependent myocardium
by influencing vasomotion of the resistance vessels in
the collateral zone. As we know, receptor-mediated, en-
dothelium-dependent dilation has been shown to be im-
paired in microvessels chronically perfused by collateral
vessels [28 ].
Donckier, et al. [29] studied 30 conscious chronically
instrumented dogs before, during and after a 10-min
coronary artery occlusion performed either during ET-1
or during saline infusion. Left anterior descending artery
blood flow decreased equally during occlusion with ei-
ther ET-1 or saline. Both endocardial and epicardial
blood flow in ischemic regions also decreased during
artery occlusion but were threefold greater with ET-1
than with placebo. These results showed that ET-1 in-
creases collateral blood flow in the ischemic myocar-
dium in dogs.
By combining coronary wedge pressure, obtained by
means of a wave wire, with simultaneously recorded
aortic pressure, obtained by means of the guiding cathe-
ter, and central venous pressure at maximum arterial
vasodilation, a quantitative index of collateral flow can
be calculated. This index, called fractional collateral
blood flow, expresses actual collateral flow as a ratio to
normal maximum myocardial perfusion. A lower ratio
indicates a higher impairment in the collateral perfusion
of the ischemic myocardium. After repeated balloon in-
flations, the coronary wedge pressure, in a group of pa-
tients administered BQ-123, decreased, whereas in the
control group it increased. These results indicate that
acute ETAR antagonism decreases coronary collateral
circulation in patients with coronary artery disease du-
ring angioplasty. Therefore, ETAR antagonism may in-
crease coronary blood flow and decrease coronary artery
resistance and distal coronary pressure by dilating the
distal arterial segments and the resistance arteries in the
nonischemic region [14].
In addition to its actions on vascular smooth muscle cells,
ET-1 is also a potent mitogen in several cultured cell
lines of both cardiovascular and noncardiovascular origin
[30]. ET-1 also induces the expression and release of
several proto-ongogenes and growth factors, the latter of
which may be synergistic [31-34].
Douglas, et al. [35] studied the role of endogenous
ET-1 in neointimal formation after rat carotid artery bal-
loon angioplasty. They showed that ET-1 promotes
neointimal formation in vivo and that it is involved in the
pathogenesis of angioplasty-induced lesion formation in
the rat. They showed also the protective effect of the
nonpeptide ETR an tagonist SB 209670 ( ETAR and ETBR
antagonist) in neointimal formation, indicating that this
substance can serve as a useful adjunct to coronary an-
gioplasty, attenuating the degree of vascular restenosis
observed after vascular wall injury. The same investiga-
tors showed that neither chronic nor acute ETAR bloc-
kade after giving BQ-123, an ETAR blockade, is suffi-
cient to inhibit angioplasty-induced neointima formation
in the rat. They implicated a significant role for the ETBR
subtype, either exclusively or in concert with ETAR acti-
vation, in the pathogenesis of neo intima formation in the
rat. The administration of BQ-123 in patients with stab le
angina undergoing angioplasty, failed to show any dif-
ference in restenosis after 6 months, as analyzed by
quantitative coronary arteriography and intravascular
ultrasound [36].
ET-1 maintains normal coronary artery tone. ETAR as-
sume a cornerstone role on the regulation of coronary
circulation. There is an upregulation of ETAR in hyper-
tension and a downregulation in diabetes. ET is a potent
promoter of neointimal formation, and ETAR blockade
inhibits restenosis after ang ioplasty in an imal model. The
secretion of ET during myocardial ischemia and reperfu-
sion is related to ischemia, rather than to endothelial in-
jury. ETAR antagonism increases coronary blood flow in
healthy coronary arteries, but may reduce coronary blood
flow in diseased segments, via a coronary steal pheno-
menon. Moreover, ETAR blockade increases the diameter
of distal coronary arterial segments and decreases coro-
nary vascular resistance. Coronary collaterals have de-
creased sensitivity to ET-1, and ETAR antagonism de-
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E. Polymeropoulos et al. / World Journal of Cardiovascular Diseases 3 (2013) 371-376 375
creases collateral blood flow and perfusion of the ische-
mic myocardium.
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