Background
The rapid expansion of the type 2 diabetes and obesity co-epidemics impacts heavily on cardiovascular health. One clinically important, but often overlooked, cardiovascular consequence is that diabetic and obese patients have increased requirements for surgical treatments. Following surgery they have longer hospital stays and poorer survival compared to non-diabetic and lean patients [
1]-[
3]. Importantly, patients with metabolic syndrome are subject to a higher incidence of perioperative haemodynamic complications, even for non-cardiac related surgeries, which most likely relates to changes in autonomic control of the cardiovascular system [
2],[
4]-[
6].
Long-term changes in metabolism, such as during the metabolic syndrome [
7], are characterised by increased muscle sympathetic nerve activity [
8],[
9] and increases in plasma (nor)epinephrine levels [
10], suggesting overall central sympathetic over-activation [
7]. Consequently, several
ex vivo studies demonstrated decreased β-AR expression in [
11]-[
14] and reduced β-AR responsiveness of [
14]-[
17] the heart in diabetes, with similar reports in obesity [
18]-[
20]. Less attention has focused on α-ARs, with
ex vivo studies or studies in anaesthetised rats variably reporting unchanged [
16],[
21], impaired [
22],[
23] or enhanced [
24],[
25] α-AR activity in the metabolic syndrome.
While the long-term metabolic stress of diabetes and obesity leads to haemodynamic dysregulation [
4],[
26], cardiovascular function is also acutely challenged in the perioperative setting [
4],[
27]. Diabetes and obesity are both known to augment cardiovascular responses to anaesthetics [
16],[
28],[
29]; and the well described cardioprotective effects of volatile anaesthetics are reduced under conditions of metabolic stress [
30]. For instance, sevoflurane elicited greater impairments in myocardial blood flow in a pilot study of type 2 diabetic patients [
31]. Isoflurane anaesthesia also impairs baroreflex responsiveness [
32], and obesity is associated with impaired baroreflex sympatho-inhibition [
33]; both effects which are thought to be mediated via augmentation of central nervous system pathways. Furthermore, Amour
et al. [
16] showed in isolated papillary muscles that type 1 diabetes attenuated the potentiation of α- and β-AR responses by halogenated anaesthetics, suggesting an interaction between anaesthetic and metabolic-mediated α- and β-AR dysfunction. However, this approach does not address the peripheral and neural effects present
in vivo, nor examine changes in type 2 diabetes. Furthermore, the lack of
in vivo data under conscious conditions, limits the interpretation of anaesthetic effects on α- and β-AR function.
Therefore, the present study aimed to assess how isoflurane anaesthesia affects the α- and β-AR-mediated haemodynamic responses in type 2 diabetes
in vivo. To assess the direct effects of anaesthesia we measured haemodynamic responses in free-moving conscious and in isoflurane anaesthetised type 2 diabetic (Zucker Diabetic Fatty (ZDF)) rats following α- and β-AR stimulation. To this end, rats were implanted with a radio telemetric transmitter and a vascular access port to measure
in vivo abdominal aortic blood pressure and inject intravenous drugs, respectively [
34]. These measures were repeated in obese (Zucker) rats to determine whether the observed changes were a specific effect of type 2 diabetes, or a more general feature of metabolic syndrome.
Discussion
This is the first study to determine the interaction between α- and β-adrenergic function and isoflurane anaesthesia in vivo under physiological conscious and anaesthetised conditions. This conscious-anaesthesia approach reveals augmented vascular α-AR sensitivity and reduced cardiac chronotropic β-AR sensitivity in conscious free-moving type 2 diabetic and obese animals. Moreover, isoflurane anaesthesia exacerbated the increased vascular α-AR sensitivity in both disease models, while normalising the chronotropic β-AR responses in obese rats and surprisingly increasing the chronotropic β-AR sensitivity in type 2 diabetic rats. These results show that chronic metabolic stress, such as during type 2 diabetes and obesity, alters α- and β-adrenoceptor function in vivo, its dynamics and the interaction with anaesthesia; reducing the haemodynamic capacity of the cardiovascular system to compensate during times of acute stress. Furthermore, the differential α- and β-adrenergic responses described in type 2 diabetes and obesity during isoflurane anaesthesia emphasise the importance of examining pharmacological effects under physiological conditions.
Several studies have found increased α-AR vascular reactivity in isolated and anaesthetised preparations from both type 1 and type 2 diabetic (20, 30, 38) and obese models (28, 29, 37). Alternatively, some studies reported unchanged [
18],[
21] or reduced [
43],[
44] vascular α-AR responses. However use of low phenylephrine doses that also failed to discern a difference in our study [
18] or nonspecific α-AR stimulation with noradrenaline [
43],[
44], may explain these differences. The present study shows augmented vascular α-AR responsiveness, in magnitude and in duration, in conscious type 2 diabetic and obese animals, at clinical doses of phenylephrine (32).
The reduced cardiac β-AR sensitivity observed aligns with and extends literature reports. During the metabolically compromised state of diabetes, it is suggested that the sympathetic drive to the heart is increased [
4],[
7], eventually desensitising the adrenergic control of the heart and reducing its function [
45]. Reduced β-AR activity has been described in both isolated heart [
14]-[
16],[
46] and in anaesthetised
in vivo preparations [
12] of streptozotocin-induced type 1 diabetes. Furthermore, we have recently described the loss of β-AR responsiveness with type 2 diabetes in human right atrial cardiac muscles [
17]. Similar findings of reduced β-AR function have been derived from heart tissue from [
19],[
20] and a single report in conscious [
18] obese rodents. However, the present study provides the first evidence of increased and prolonged vascular α-AR sensitivity and reduced chronotropic β-AR sensitivity in well-developed models of both type 2 diabetes and obesity
in vivo under conscious conditions.
While the mechanisms underlying the altered AR function are poorly understood, and determination was not the aim of this study, changes in AR expression have been implicated. Elevated cardiovascular α
1-AR expression has been described in various models of the metabolic syndrome [
46]-[
48], although decreased α-AR density has also been reported [
48],[
49]. This α
1-AR variability is proposed to be attributable to disease duration [
24],[
49], with a biphasic expression pattern providing a compensatory response to the progressive α-AR sensitisation [
48],[
49]. However, during ganglionic blockade α-AR responsiveness was found to be unchanged, indicating that the effect may originate downstream [
21]. Decreased expression of β
1-ARs was shown in myocardium of type 1 diabetic rodent models [
11],[
13],[
50]. However, we found unchanged β
1-AR expression in right atrial tissue from type 2 diabetic patients [
17]. Similarly, Carroll
et al. [
42] found unchanged overall β-AR density in obese rabbit ventricles, and similar to α-ARs, suggested that defective β-AR function in obesity may originate downstream of the receptors themselves. Moreover, we have recently shown that the haemodynamic effects observed using our technique are not due to the potential confounders of volume or injection stress in conscious animals [
34]. Thus, further research, particularly into expression and function of α-AR in the vasculature and β-AR in the sinoatrial node, is warranted to explain these haemodynamic and chronotropic differences.
Much of the previous experimental evidence for α- and β-AR-dysfunction has been derived from models of type 1 diabetes, and conducted in anaesthetised or isolated heart or vessel preparations. Therefore, this study, using improved conscious
in vivo techniques, confirms the relevance of these α- and β-AR-dysfunctions in type 2 diabetes and obesity under physiological conditions and provides valuable new insights. Additionally, the paucity of suitable data in conscious animals has made it difficult to elucidate the effects of anaesthetics per se, and few investigations have addressed this issue. Amour
et al.[
16] showed in an interesting study that halogenated anaesthetics, including isoflurane, increased both α-AR and β-AR inotropic responses in isolated hearts. This is supported by our observation of enhanced β-AR-generated HR responses in type 2 diabetic animals, but not by the absence of isoflurane-potentiated β-AR chronotropic responses in non-diabetic rats or the reduced α-AR sensitivity. This indicates the importance of
in vivo investigations, including neural, hormonal and vascular feedbacks, which are most likely geared to compensate for excessive fluctuations in the cardiovascular system.
It is unclear how defects exclusively at the α- and β-ARs themselves would directly interact with anaesthesia. Likewise, simple interruption of central autonomic signalling by anaesthetics would be unlikely to selectively interact with α-AR function. The phenylephrine-generated baroreflex-induced changes in HR were overall markedly depressed under isoflurane. Thus, it could be speculated that isoflurane prevents appropriate central control of sympathetic withdrawal during MAP elevation in the vasculature causing an anaesthetic-mediated exacerbation of α-AR sensitisation in type 2 diabetic and obese rats.
By utilising models of type 2 diabetes and obesity with a common underlying defect in leptin signalling, we were able to directly address the influence of hyperglycaemia. The observed alterations in α- and β-AR function were broadly similar between type 2 diabetic and obese rats. Thus, these impairments are likely to be a function of the general metabolic syndrome components of overweight and insulin resistance, rather than the hyperglycaemic phenotype of diabetes; in agreement with previous findings that α- and β-AR dysfunction is not tied to the development of type 2 diabetes [
51]. Furthermore, as the effects were more severe in morbidly obese rats, and less pronounced in the overweight type 2 diabetic animals, it appears that obesity may be the primary causal defect.
Regardless of the cause of exacerbated metabolic α- and β-AR dysfunction, differences in α- and β-AR responsiveness (in magnitude and duration) remain an important consideration in this large patient group. During chronic metabolic stress, such as obesity and type 2 diabetes, sympathetic drive to the heart is suggested to be increased [
4],[
7]; which may be partially offset by the observed reduction in β-AR sensitivity. Enhanced and prolonged α-AR responsiveness and the resultant chronic excess cardiovascular pressure could lead to cardiac complications, including increased afterload, cardiac remodelling and hypertrophy [
52]. During anaesthesia, the dual effects of exacerbating differences in α-AR response and normalising β-AR function will likely act in concert in type 2 diabetes and obesity to further increase cardiovascular stress. This indicates that chronic metabolic stress limits the capacity of the cardiovascular system to respond when challenged by acute stressors such as anaesthesia. In particular, the interaction between metabolic syndrome and anaesthesia to exaggerate phenylephrine-mediated elevations in MAP suggests that type 2 diabetic and obese patients may be exposed to increased pharmacological stress during surgery.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
All authors contributed to research design and interpretation of data. RL conceived of the study, with experiments and analysis performed by CB and AdL. CB drafted the manuscript and revised it with input from all authors. All authors approved the final version of the manuscript.