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(Circulation. 2003;108:2224.)
© 2003 American Heart Association, Inc.

Clinical Investigation and Reports

Dynamic Regulation of Sodium/Calcium Exchange Function in Human Heart Failure

From the Department of Physiology, Loyola University Chicago, Stritch School of Medicine, Maywood, Ill (C.R.W., D.M.B.); and the Molecular and Cellular Cardiology Laboratories, Cardiovascular Research Group, Temple University School of Medicine, Philadelphia, Pa (V.P., S.R.H.).

Correspondence to Donald M. Bers, PhD, Department of Physiology, Loyola University Chicago, 2160 South First Ave, Maywood, IL 60153. E-mail dbers{at}lumc.edu

Received April 2, 2003; de novo received June 4, 2003; revision received August 8, 2003; accepted August 13, 2003.

	Abstract

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Background— Sarcolemmal Na/Ca exchange (NCX) regulates cardiac Ca and contractility. NCX function during the cardiac cycle is determined by intracellular [Ca] and [Na] ([Ca]_i, and [Na]_i) and membrane potential (E_m), which all change in human heart failure (HF). Therefore, changes in NCX function may contribute to abnormal Ca regulation in human HF.

Methods and Results— We assessed the cellular bases of differences in NCX function in ventricular myocytes from failing (F) and nonfailing (NF) human hearts. Allosteric activation of NCX by [Ca]_i was comparable in F and NF myocytes (K_1/2=150±31 nmol/L, n=7). The steady-state relation between [Ca]_i and NCX current (I_NCX) was used to infer the local submembrane [Ca]_i ([Ca]_sm) that is sensed by NCX dynamically during the action potential (AP) and Ca transient (37°C). This involved tail I_NCX measurement during abrupt repolarization of APs and Ca transients, where peak inward I_NCX indicates [Ca]_sm. This allows inference of the direction of Ca transport by the NCX during the AP. In NF myocytes, NCX extrudes Ca for most of the AP. Three factors shift the direction of NCX-mediated Ca transport (to favor more Ca influx) in F versus NF myocytes, as follows: (1) reduced [Ca]_sm, (2) prolonged AP duration, and (3) elevated [Na]_i.

Conclusions— These results show that Ca entry through NCX may limit systolic dysfunction due to reduced sarcoplasmic reticulum Ca stores in HF but could contribute to slow decay of the [Ca]_i transient and to diastolic dysfunction.

Key Words: heart failure • calcium • sodium • contractility

	Introduction

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Sarcolemmal Na/Ca exchange (NCX) competes with sarcoplasmic reticulum (SR) Ca-ATPase in causing systolic Ca transient decline and relaxation.¹ In many hypertrophy and heart failure (HF) models, NCX expression is increased,^2–6 and this could enhance the contribution of NCX to twitch relaxation. Because NCX and SR Ca-ATPase compete during [Ca]_i decline, reduced SR Ca-ATPase function indirectly favors greater NCX contribution to relaxation (even without altered NCX expression or properties).^1,7 In addition, NCX function is strongly influenced by [Ca]_i, [Na]_i, and membrane potential (E_m), all of which change in HF. Typically in HF (versus control), Ca transients are smaller in amplitude and decline more slowly,^8,9 [Na]_i is higher,^10,11 and action potential duration (APD) is prolonged.^4,12,13 These would all reduce Ca extrusion through NCX during the cardiac cycle and bias NCX toward Ca influx. In addition, local submembrane [Ca]_i ([Ca]_sm) sensed by NCX during normal Ca transients is higher than global [Ca]_i measured by fluorescent Ca indicators.^14,15 Thus, quantitative analysis of NCX function is imperative to understand how NCX functions during action potentials (AP) in human HF.

When E_m is negative to the NCX reversal potential (E_NCX=3E_Na-2E_Ca), Ca extrusion is favored (inward NCX current, I_NCX), whereas E_m above E_NCX favors Ca entry (outward I_NCX). As [Ca]_i, [Ca]_sm, and E_m change during the AP, net I_NCX changes dynamically. Low [Ca]_i, high [Na]_i, and long APD favor Ca entry through NCX. Our goal here is to evaluate how NCX functions during the AP in ventricular myocytes from failing (F) and nonfailing (NF) human hearts.

We show that Ca entry through NCX is readily demonstrable, characterize allosteric NCX activation by [Ca]_i, determine [Ca]_sm during normal AP, and infer the actual Ca flux through NCX during the AP. In NF myocytes, NCX primarily extrudes Ca throughout the cardiac cycle. However, in typical F myocytes, there is substantial Ca entry through NCX during the AP (explaining the slowly rising [Ca]_i seen in many F myocytes). Additionally, we demonstrate how important thermodynamic determinants are (versus number of NCX molecules) to NCX behavior.

	Methods

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Cell Isolation, Electrophysiology, and [Ca]_i Measurement
Myocytes were isolated from F and NF human hearts as described previously and were from the same 11 F and 7 NF patients (mean ejection fractions were 17.5±4.9% and 54.1±4.6% by echocardiography).⁷ E_m and current were controlled and recorded using discontinuous, single-electrode voltage clamp at 37°C. Ca signals were recorded with the use of fluo-3.

Solutions Used for Electrophysiological Recording
Pipettes (1 to 3 M) were filled with the following (in mmol/L): 130 cesium aspartate, 20 tetraethylammonium chloride, 1 MgCl₂, 10 HEPES, 2.5 NaCl, 5 Na₂ATP, and 0.1 potassium–fluo-3, pH 7.2, using CsOH at 37°C. Total [Na] (12.5 mmol/L) was based on human myocyte estimates.¹⁰ Seals were attained in solution (normal Tyrode) containing the following (in mmol/L): 150 NaCl, 5.4 KCl, 10 glucose, 5 HEPES, and 1 MgCl₂, 1 CaCl₂, with pH 7.4 at 37°C using NaOH. After patch rupture, 30 µmol/L niflumate and 3 mmol/L 4-aminopyridine were added (to block Ca-activated chloride and potassium currents), and CsCl replaced KCl.

Allosteric Ca Activation of I_NCX
Cells were pretreated with 1 µmol/L thapsigargin to block SR Ca-ATPase and 20 µmol/L nifedipine-blocked L-type Ca channels. E_m was initially -100 mV to keep [Ca]_i low but then oscillated between +100 mV and -100 mV to drive Ca flux through I_NCX.¹⁶

Time Course of [Ca]_sm During AP
Nifedipine and thapsigargin were omitted, allowing normal excitation contraction coupling (ECC). A typical AP, recorded with physiological solutions at 1 Hz (37°C) from a F human myocyte, was used as an AP-clamp waveform. AP clamps were interrupted at 10 to 500 ms by repolarization to -70 mV, yielding tail I_NCX. Capacitative current and I_Ca were subtracted,¹⁵ leaving only I_NCX, which was used to infer [Ca]_i sensed by NCX ([Ca]_sm).

Steady-State I_NCX Versus [Ca]_i
The steady-state relation between [Ca]_i and I_NCX is described in the Equation.^15,16

The three factors are allosteric regulation by [Ca]_i, which is not transported (Allo), competitive binding of Na and Ca as substrates (Bind) and the effects of E_m (Elect). The latter two combined give an electrochemical term. K_m values are intracellular (i) and extracellular (o) Na and Ca dissociation constants. K_mCaAct=150 nmol was determined here; other constants are as in Reference ¹⁵. Maximal I_NCX flux (V_max) was determined for each cell by using the measured [Ca]_i dependence of I_NCX (V_max=8.8±3.6 and 6.8±1.8 A/F for NF and F), consistent with unaltered NCX mRNA and [Ca]_i dependence in these F hearts.⁷

	Results

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Ca Fluxes Through NCX
Slow depolarizing voltage ramps from -100 mV (Figure 1A) show Ca entry through I_Ca and I_NCX (with SR function blocked). [Ca]_i increased biphasically with depolarization (see also rate of [Ca]_i rise, d[Ca]_i/dt). Figure 1B shows that d[Ca]_i/dt rises, with a hump between -25 and +30 mV reflecting Ca entry through I_Ca, and rises again at more positive E_m (as Ca entry through I_Ca declines and that through I_NCX rises). Moreover, d[Ca]_i/dt attributable to I_NCX reaches levels comparable to that through I_Ca and drives [Ca]_i considerably higher. These Ca fluxes emphasize that substantial Ca entry can occur through I_NCX (and was similar in F or NF human myocytes).

View larger version (21K): [in this window] [in a new window]   Figure 1. Voltage ramp activating ICa and NCX. A, Em, [Ca]i, d[Ca]i/dt, and INCX during protocol (average from 3 thapsigargin-treated myocytes [2 F, 1 NF]). B, d[Ca]i/dt versus Em during ascending ramp shows 2 Ca entry phases through ICa (+10 mV) and INCX (>50 mV). C, Ca removal by NCX; blue indicates d[Ca]tot/dt (where [Ca]tot=[Ca]i+231/{1+833/[Ca]I}), red is measured INCX (x13 pF/pL÷96 490 C/mol), and dashed curve is the Equation (Vmax=5.1 A/F, [Na]i=12.5 mmol/L).

Repolarization promotes Ca removal by NCX, shown three ways in Figure 1C. One is based on d[Ca]_i/dt (after correcting for cytosolic Ca buffering).⁷ The solid red curve is measured I_NCX (corrected for surface-to-volume ratio=13 pF/pL).⁷ The dashed curve is based on the Equation (using V_max=5.1 A/F, pipette [Na]_i=12.5 mmol/L, and the measured [Ca]_i and E_m). This demonstrates that [Ca]_i decline correlates well with measured I_NCX and also that the Equation describes well the [Ca]_i dependence of I_NCX in human ventricular myocytes.

During the cardiac cycle, E_m, [Ca]_i, and [Na]_i all influence I_NCX activity electrochemically (and [Ca]_i activates NCX allosterically), even at constant NCX expression. Figure 2 illustrates the independent effects of E_m, [Na]_i, and [Ca]_i on outward I_NCX, using the Equation. As E_m increases from 0 mV to +100 mV, outward I_NCX increases dramatically (Figure 2A), corresponding with the progressive rise in d[Ca]_i/dt at positive E_m in Figure 1A. Figure 2B shows how increasing [Na]_i promotes outward I_NCX. Alterations in [Ca]_i have complex effects on outward I_NCX because the electrochemical and allosteric effects are directionally opposite (Figure 2C). As [Ca]_i rises, outward I_NCX at +20 mV (Ca influx) first increases as a result of allosteric Ca activation, but at higher [Ca]_i the electrochemical effect becomes more dominant and outward I_NCX decreases. For inward I_NCX (E_m=-80 mV), higher [Ca]_i increases both allosteric and electrochemical factors.

View larger version (21K): [in this window] [in a new window]   Figure 2. Outward INCX depends on Em, [Na]i, and [Ca]i (using the Equation). A, Em dependence of INCX at constant [Na]i and [Ca]I; B, [Na]i dependence of INCX at 125 nmol/L [Ca]i; C, [Ca]i dependence of INCX at 12.5 mmol/L [Na]i.

Allosteric Activation of I_NCX
We measured allosteric activation of I_NCX in intact human myocytes (with other transporters and channels blocked),¹⁶ using E_m to control I_NCX direction (Figure 3B and 3C). Outward I_NCX at +100 mV drives Ca entry, whereas inward I_NCX extrudes Ca at -100 mV, creating [Ca]_i oscillations (Figure 3A). During each pulse, I_NCX and [Ca]_i values were taken to create Figure 3D. Inward I_NCX at -100 mV increases as [Ca]_i rises, as a result of both allosteric Ca activation and increased thermodynamic driving force. Outward I_NCX at +100 mV decreases with rising [Ca]_i, (reduced driving force), but the increase in outward I_NCX with [Ca]_i must be attributed to allosteric activation. Figure 3D shows mean fits of the Equation to both the inward and outward I_NCX. There was no major difference detected between F and NF human myocytes, and the mean allosteric K_mCaAct was 150±31 nmol/L.

View larger version (29K): [in this window] [in a new window]   Figure 3. Allosteric Ca activation of INCX. A through C, INCX, [Ca]I, and Em in an NF myocyte; D, INCX versus [Ca]i from 4 F myocytes (solid symbols) and 3 NF myocytes (open symbols, different shapes for each cell). Solid lines show the Equation fit, using the average KmCaAct determined from individual cell fits (KmCaAct=150±31 nmol/L, n=7). Data are normalized to [Ca]i=1 µmol/L.

Submembrane [Ca] and I_NCX During AP
Fluorescent indicators do not sense local [Ca]_sm near the NCX. This is a minor complication for Figure 3 but more problematic when I_Ca and SR release are functional, and [Ca]_sm may far exceed bulk [Ca]_i.¹⁵ High [Ca]_sm biases I_NCX in the inward direction versus that expected from [Ca]_i. Using our novel approach developed in rabbit myocytes,¹⁵ we assessed [Ca]_sm in human F and NF myocytes. This allows more direct evaluation of NCX function during the AP.

Peak twitch [Ca]_i is lower in F versus NF human myocytes.⁷ In Figure 4A, the AP was interrupted at different times and I_NCX tails were measured at -70 mV (Figure 4B). Here, I_Ca, SR Ca transport, and ECC are fully functional. Conditioning pulses before each test AP ensured steady-state SR Ca loading. We plot measured I_NCX versus [Ca]_i (Figure 4D) and compared initial I_NCX with the steady-state relation (fitting the Equation to the late [Ca]_i decline; thick line in Figure 4D). Initial I_NCX is higher than expected for [Ca]_i, and we extrapolate [Ca]_sm from I_NCX (at the moment of repolarization) to the steady-state curve. Repeating this procedure at different times allows reconstruction of the [Ca]_sm versus global [Ca]_i transient in this HF cell (Figure 4E).

View larger version (33K): [in this window] [in a new window]   Figure 4. Protocol to measure [Ca]sm. A, AP was interrupted and clamped to -70 mV at various times in one F myocyte; B, INCX tails at -70 mV; C, [Ca]i for AP interruptions; D, INCX versus [Ca]i from B and C. Traces intersect steady-state (SS) INCX versus [Ca]i relation for this cell (Equation; Vmax=10.9 A/F, [Na]i=12.5 mmol/L, Em=-70 mV, with leak offset=0.17 A/F). Arrows illustrate extrapolation from INCX to [Ca]sm. E, [Ca]sm and [Ca]i.

Figures 5B and 5C show averaged [Ca]_i and [Ca]_sm transients from 5 NF and 4 F myocytes. Figure 5D shows I_NCX, based on [Ca]_sm and E_m during the AP (using the Equation).

View larger version (17K): [in this window] [in a new window]   Figure 5. Pooled [Ca]sm data and inferred INCX during AP. A, AP. B, Mean [Ca]i from 5 NF and 4 F myocytes (from 3 NF and 2 F hearts). C, Mean [Ca]sm determined as in Figure 4. D, INCX calculated from the Equation, using [Ca]sm and Em (Vmax=8 A/F, [Na]i=12.5 mmol/L, [Ca]o=1 mmol/L, [Na]o=152 mmol/L). E, Integrated INCX in panel D converted to [Ca]tot, (using 13 pF/pL).7

In NF human myocytes, I_NCX is inward for almost the entire AP, except very briefly early in the AP. The first inward current hump is driven largely by high [Ca]_sm, whereas the later inward hump is driven mainly by repolarization. Integrated Ca flux by I_NCX (Figure 5E) reaches >30 µmol Ca/L cytosol. We calculate that to reach the observed peak [Ca]_i requires 120 µmol Ca/L cytosol (based on our cytosolic Ca buffering measurement).⁷ This implies that NCX extrudes 25% of activator Ca during the cardiac cycle in NF human myocytes (matching values from simpler analysis of [Ca]_i decline).⁷

In HF, there is substantial outward I_NCX during the AP (Figure 5D). This is largely due to lower peak [Ca]_i, since the AP-clamp was identical and 12.5 mmol/L [Na]_i was used for F and NF in both the pipette and calculations. Thus, the low [Ca]_i and [Ca]_sm cause sufficient outward shift in I_NCX to bring in substantial Ca during the AP. The integral in Figure 5E peaks at +12 µmol Ca/L cytosol before repolarization causes I_NCX to switch directions and extrude Ca. This suggests significant Ca entry during the AP in HF, which can contribute to the Ca transient and contraction (thereby limiting the negative inotropic impact of reduced SR Ca content).⁷ The mean rate of Ca influx through I_NCX during 100 to 300 ms of the HF AP (Figure 5D) is 36 µmol/L cytosol/s. This is almost identical to the gain in Ca based on the slow rise in [Ca]_i during this time in Figure 5B (35 µmol/L cytosol/s; accounting for cytosolic buffering). We conclude that this slowly rising [Ca]_i during the HF AP is largely due to Ca entry through NCX. Figure 5E shows that by end-diastole in HF (1 second at 1 Hz), NCX has extruded a net 20 µmol/L cytosol. Thus, in the HF case, NCX can remove the Ca that entered through NCX and I_Ca. At a heart rate of 1.5 Hz, Ca would tend to accumulate in F myocytes, but APD also shortens, reducing Ca entry and allowing more time for diastolic Ca extrusion through I_NCX.

Figure 5 is appropriate for myocytes studied here (with some cellular dialysis), but in NF versus F myocytes, the APD is shorter and [Na]_i is lower.^7,10,11 Figure 6A extends our analysis to simulate NF conditions, with shorter AP duration (by 100 ms), different [Na]_i values, Ca transient as in Figure 5 (but with 10% faster [Ca]_i decline), and at [Ca]_o=1.25 mmol/L (physiological free [Ca]_o).¹⁷ The rate and integral of SR Ca pumping is also shown. For NF cells ([Na]_i=8 to 10 mmol/L), Ca transport through NCX is similar to that shown in Figure 5, consistent with [Na]_i in NF cells.¹⁰ In F myocytes (versus NF), there is more Ca influx through NCX at any [Na]_i. This effect is more pronounced at the elevated [Na]_i (12 mmol/L) in HF.^10,11

View larger version (24K): [in this window] [in a new window]   Figure 6. Effect of [Na]i on INCX. A, NF INCX from the Equation, with APD shortened by 100 ms and [Ca]sm proportionately shortened. B, INCX in F myocyte calculated using the Equation (F AP as in Figures 5 and 6). For panels A and B, Vmax=8 A/F, [Na]i=8 to 12 mmol/L, [Ca]o=1.25 mmol/L, [Na]o=140 mmol/L), and SR Ca transport was calculated by using measured NF and F parameters.7 C and D, Integrated INCX converted to [Ca]tot.

In the F simulations at 12 mmol/L [Na]_i, NCX barely extrudes the Ca that entered during the AP and at 1 second has only extruded 5 µmol/L of the Ca that enters through I_Ca (net extrusion does not reach 13 µmol/L cytosol until 1.9 seconds). At 1 Hz, this would cause cellular Ca gain, larger Ca transients, and consequently a greater Ca extrusion, until a new steady state is attained (where Ca influx and efflux are balanced during the cardiac cycle). Ca extrusion rate through NCX is relatively low during the AP versus SR Ca pump, but on repolarization the Ca flux rates are more comparable.

	Discussion

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We quantitatively characterized NCX function during APs in human ventricular myocytes (F and NF) for the first time. Our major findings are the following. (1) Allosteric NCX activation by [Ca]_i in F and NF myocytes occurs at physiological [Ca]_i (K_m=150 nmol/L). (2) [Ca]_sm sensed by NCX during normal Ca transients exceeds bulk [Ca]_i. (3) In NF myocytes, NCX extrudes Ca nearly throughout the cardiac cycle. (4) In F myocytes, substantial Ca enters the cell through NCX during the AP, as a result of lower [Ca]_i, prolonged APD and higher [Na]_i in HF.

Allosteric Regulation of Human NCX by [Ca]
Estimates of Ca affinity of the allosteric NCX site vary from K_mCaAct of 22 to 125 nmol/L in intact myocytes^18,16 to 300 to 600 nmol/L in giant excised patches.¹⁹ The higher excised patch values might reflect loss of some unknown NCX regulator. Although our protocol measures physiologically relevant NCX activation by Ca, K_mCaAct could be slightly underestimated because we use [Ca]_i versus [Ca]_sm (but this is a minor issue here versus during SR Ca release). Nevertheless, we conclude that as [Ca]_i increases in human myocytes, NCX activates much like ferret, canine,¹⁶ and rabbit NCX (Weber and Bers, unpublished observation, 2002), but unlike mouse NCX, which displays weak allosteric Ca regulation at physiological [Ca]_i.¹⁶ Furthermore, we did not detect a difference in allosteric Ca activation between F and NF myocytes, consistent with unaltered [Ca]_i dependence of I_NCX in Reference ⁷.

Allosteric Ca activation augments inward and outward I_NCX. As [Ca]_i rises during an AP, Ca activation will activate NCX molecules regardless of the direction favored thermodynamically. This could enhance Ca influx early in the AP (and later in HF), but as [Ca]_i (and [Ca]_sm) increase, NCX switches direction to Ca efflux. At this time, inward I_NCX will be stimulated by allosteric activation, thermodynamic driving force, and higher substrate concentration. This accelerates Ca extrusion through NCX. As [Ca]_i approaches diastolic levels, NCX partially deactivates, helping to prevent [Ca]_i from going too low. This K_mCaAct (150 nmol/L) may help to set diastolic [Ca]_i near to but below the threshold for contractile and ryanodine receptor activation and allow NCX to optimally stabilize resting [Ca]_i. This K_mCaAct may also keep NCX partially active for the next beat.

[Ca]_sm Sensed by NCX
During SR Ca release, inward I_NCX rises more rapidly than bulk [Ca]_i.^14,20,21 However, one cannot simply block I_NCX (or other currents) to measure physiologically relevant I_NCX because it is interdependent on I_Ca and SR Ca release. In our quantitative approach developed in rabbit ventricular myocytes,¹⁵ peak [Ca]_sm was 3-fold higher than peak [Ca]_i and occurred much earlier with respect to the AP upstroke (<30 versus 81 ms). From this [Ca]_sm transient (and E_m dependence of I_NCX), we inferred that I_NCX is inward for almost the entire normal rabbit cardiac cycle. This analysis reflects how average NCX molecules function, but individual NCX molecules that are closer to Ca entry or release sites would sense higher [Ca]_sm. During SR Ca release, [Ca]_cleft near ryanodine receptors may be >10 times higher than the average [Ca]_sm sensed by NCX. NCX molecules nearest the cleft would sense higher [Ca]_sm (and earlier), causing those NCX molecules to shift to Ca extrusion even earlier during the AP. Thus, the submembrane space here is not anatomically defined but is functionally defined by average NCX behavior.

In F and NF human ventricular myocytes (37°C), we found that even with unaltered NCX expression or properties,⁷ changes in [Ca]_i, [Na]_i, and E_m characteristic of HF alter I_NCX during the AP (Figure 5). Our results with NF human and rabbit ventricular myocytes¹⁵ are similar. That is, the rapid [Ca]_sm rise causes I_NCX to be almost entirely inward (extruding Ca) throughout the cardiac cycle. In contrast, I_NCX differs in F human myocytes, which exhibit a small early peak [Ca]_i and slowly rising [Ca]_i during the AP. The lower [Ca]_sm during the AP plateau causes substantial Ca entry through I_NCX. This functional difference between F and NF human myocytes is further magnified when we account for the longer AP duration and elevated [Na]_i seen in F versus NF myocytes (Figure 6). Previous simulations of I_NCX in HF (human and rabbit) suggest such an outward shift in I_NCX,^11,22 but in this study we demonstrate this directly. Indeed, Despa et al¹¹ compared how altered [Ca]_i, [Na]_i, and APD in rabbit HF are expected to influence Ca entry through I_NCX. Higher [Na]_i was the most effective, but all would contribute in HF.

Not all F human myocytes show the prominent and typical phenotype in Figure 5B. About 50% of F cells exhibit various intermediate phenotypes between that in Figure 5B and the NF phenotype (although overall mean Ca transients were clearly smaller and slower in F).⁷ Thus, there is cellular heterogeneity, but in many F human ventricular myocytes there is clearly sufficient Ca entry through NCX during the AP to boost [Ca]_i. This Ca entry may contribute directly to support contraction by enhancing Ca binding to myofilaments and limiting the reduction in SR Ca load. If this shift in NCX fluxes did not occur in HF, the degree of systolic dysfunction would be even worse.

Similar qualitative conclusions were made for a nonischemic rabbit HF model, but [Ca]_sm was not measured.^4,11 That is, reduced Ca transients, elevated [Na]_i, and prolonged APD caused similar shifts in I_NCX during the AP. Thus, these conclusions have broad impact with respect to excitation-contraction coupling in HF (although rat and mouse models that lack AP plateau may differ).

We previously considered possible sources of error in this method,^15,23 but these effects are small and occur very early during the AP and so do not affect our conclusions.

Balance of Ca Fluxes During the Cardiac Cycle
Many studies report elevated NCX expression in HF,^2–5,24 which could partly compensate for lowered SR Ca pump activity⁵ in preserving relaxation rate and diastolic function. However, either reduced SR Ca pump function or increased Ca extrusion through NCX shift Ca from the SR out of the cell, unloading the SR.^2–5,25,26 In the human hearts studied here, the [Ca]_i dependence of I_NCX was unaltered in F versus NF, so the reduced SR Ca-pump function is more important in reducing SR Ca content.⁷ Notably, SR Ca content is reduced despite the shift toward outward I_NCX during the AP. Indeed, unaltered I_NCX properties do not preclude major alterations in NCX function. In F versus NF, lower [Ca]_sm allows NCX-mediated Ca influx during the AP, but slowed [Ca]_sm decline drives an increase in NCX-mediated Ca efflux during diastole (Figure 5D).

In F, there is less SR Ca release (due to lower SR Ca content) and greater Ca influx (due to less Ca-dependent I_Ca inactivation, longer APD, and Ca entry through I_NCX). Thus, there must also be less SR Ca uptake and greater Ca extrusion through NCX during the cardiac cycle. This must be true, regardless of details. Although most aspects of our quantitative analysis agree with former work, net extrusion of >30 µmol/L Ca during a cardiac cycle implies an equal amount of Ca entry, presumably through I_Ca. This is somewhat higher than expected for integrated I_Ca influx during the AP¹ but is consistent with 25% of the 120 µmol/L cytosol of activator Ca crossing the sarcolemma. It is possible that we underestimate how completely NCX shuts off during diastole. Thus, although the present quantitative analysis is valuable, further refinement should be sought.

In conclusion, I_NCX reverses physiologically, making knowledge of [Ca]_i, [Na]_i, and E_m essential in understanding I_NCX. Thermodynamic factors are as important as protein expression levels. In NF human myocytes, Ca extrusion through I_NCX occurs almost throughout the cardiac cycle, whereas in F myocytes, substantial Ca entry occurs through I_NCX during the AP. This Ca entry depends on lower peak [Ca]_i, higher [Na]_i, and prolonged APD in F myocytes. This may limit the systolic dysfunction observed in HF but could also slow relaxation and worsen diastolic dysfunction.

	Acknowledgments

 
This study was supported by National Institutes of Health grants HL-30077 and HL-64098 (Dr Bers), HL-33921 and HL-61495 (Dr Houser), and American Heart Association predoctoral fellowships (Drs Weber and Piacentino). We thank Drs K.S. Ginsburg and K.B. Margulies for their help.

	Footnotes

 
Drs Weber and Piacentino contributed equally to this work.

	References

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