Extracellular ATP act as a co-transmitter in vagal cardiovascular reflexes. Mechanical stimulation promotes the opening of pannexin and connexin hemichannels to release ATP from the cardiomyocytes
[8][9]. Gap junction channels composed of connexin provide a means of communication between adjacent cardiomyocytes for contraction coordination
[10]. Among the connexin isoforms, the connexin-43 hemichannel is predominantly distributed in the heart, being the most prominent in the ventricles
[11]. Under physiological conditions, the connexin-43 hemichannel localized in the sarcolemma of cardiomyocytes and remained closed. The gating of hemichannels is positively regulated by mitogen-activated protein kinase (MAPK)
[12], protein kinase A (PKA)
[13], and protein kinase C (PKC)
[14], and protein phosphatase indirectly blunted the opening via dephosphorylation of the connexin-43 single channel
[15]. Unlike connexin-43, the pannexin-1 channel does not involve gap junction formation but instead forms a protective functional pannexin-1/P2X7 complex, mediating the release of adenosine and ATP in a brief period of ischemic/reperfusion (I/R)
[16]. Additionally, pannexin 2 is predominantly involved in ATP release in atrial myocytes in response to macrophage infiltration
[17]. Several conditions and mediators promote pannexin-1 channel opening, including mechanical stress
[18], ATP
[19], cytoplasmic Ca
2+ [20], and extracellular potassium
[21]. In comparison, the channel closing is regulated by the negative feedback of ATP
[22] and several channel blockers, namely carbenoxolone and probenecid
[23].
In cardiomyocytes, the selectivity of ATP towards P2X receptors was determined by the effective concentration (EC
50) value, which shows that P2X2, P2X4, P2X5, and P2X6 exert higher ATP selectivity than P2X7, but lower as compared to P2X1 and P2X2
[24][25]. Notably, P2X4 has been identified by several studies to be highly expressed in cardiac ventricular, hence its critical role in contractile performance
[25][26]. A study by Musa’s group described the variation of cardiac P2X receptor distribution in different regions of different species
[27]. The group recognized P2X4 and P2X7 as highly expressed receptors in the human right atrial and sinoatrial node using quantitative polymerase chain reaction and in situ hybridization. In contrast, a high abundance of P2X5 receptors was detected in the rat hearts’ left ventricle, right atrial, and sinoatrial node
[27]. The physiological significance of ATP-mediated P2X receptor activation has been highlighted in an overexpression study of the P2X4 receptor in human ventricular myocytes. The stimulation of agonists ATP and 2-methylthioadenosine-5′-o-triphosphate (2-MeSATP) on the highly expressed P2X4 receptors augments basal cardiac contractility without provoking a hypertrophic-induced heart failure
[25][28][29]. This beneficial cellular response was later supported by the pharmacological treatment of MRS2339, a hydrolysis-resistant adenosine monophosphate derivative that improves the cardiac output of in vitro and in vivo working heart models
[30].
On the other hand, ATP is a natural selective agonist for four subtypes of P2Y receptors, including P2Y1, P2Y2, P2Y4, P2Y6, and P2Y11. These receptors are GPCRs that form a specific isoform with either Gq, Gs, and G12/13 alpha subunit
[31][32]. The coupling of these receptors with Gq protein initiates the phospholipase C (PLC)/phosphatidylinositol-4, 5-bisphosphate (PIP2)/inositol triphosphate (IP3)-dependent Ca
2+ mobilization and the activation of monomeric G proteins, Ras homolog family member A (RhoA), and Rac in cardiac muscle
[33][34]. Additionally, ATP-induced P2Y11-Gs coupling yielded an increase in adenylate-cyclase-regulated cAMP production (
Table 1). Interestingly, ATP-activated P2X6-G12/13 coupling in cardiomyocytes is revealed to be turned on right after the development of myocardial hypertrophy via the Gq-mediated pathway activated by the same receptor and agonist
[35]. The G12/13 coupling mediates excessive production of fibrogenic factors, including transforming growth factor (TGF)-β, connective tissue growth factor (CTGF), and periostin in a Rho-dependent manner. This leads to the excessive deposition of extracellular matrix (ECM) proteins and, consequently, cardiac-fibrosis-induced heart failure.
An early study by Braun et al. (2010) characterized high activation of purinoceptor subtypes P2Y2 by ATP and UDP stimulation, increased collagen synthesis, and the expression of α-SMA, TGF-β, and PAI-1 in CFs
[37]. The same group later revealed that connexin-43 and -45 hemichannel opening contributed to the release of ATP from CFs in response to hypotonic stimulation (
Table 1). This substantially activates P2Y2-mediated pro-fibrotic marker production, including α-SMA, PAI-1, and monocyte chemotactic protein-1 (MCP-1), in an extracellular signal-regulated kinase (ERK)-dependent manner
[38]. The group then discovered the counterbalancing effect of ATP release in adult rat CFs. The hydrolysis of extracellular ATP released endogenously from CFs produces adenosine, which provides an anti-fibrotic response dependent on adenosine subtype 2B (A2B) receptors and activation of the cyclic adenosine monophosphate (cAMP)-PKA pathway
[39]. Overexpression of A2B receptors accompanied by an increased level of cAMP is critically involved in the inhibition of CF proliferation
[40][41]. Additionally, another group reported that stimulation of A2B receptors yielded a significant reduction in endothelin-1 (ET-1)-induced a-SMA expression dependent on cAMP/Epac/PI3K/Akt signalling pathways in CFs
[42]. Disturbance of collagen turnover implicates the balance between synthesis and degradation of ECM proteins, leading to irreversible replacement fibrosis, as can be seen in extensive ventricular remodelling associated with heart failure.
4. Vascular Smooth Muscle Cells
Vascular smooth muscle cell (VSMC) proliferation is detrimental to vascular remodelling, growth, and the development of atherosclerotic cardiovascular disease
[43]. The extracellular ATP acts as a potent stimulator for P2 receptors in the vascular smooth muscle cells (VSMCs), regulating blood vessel contraction and mitogenic effect. Pannexin-1 and connexin-43 are contributors to ATP release channels on VSMCs. Pannexin-1-released ATP regulates vasoconstriction intensity, triggered by the binding of phenylephrine on α1-adrenoreceptor
[44][45]. ATP and other nucleotides are also released from the necrotic VSMCs due to the loss of membrane integrity
[44][46]. In VSMCs, high ATP is released to act as a danger signal that alerts the circulating neutrophil to promote a wound-healing response. A study by Domenick’s group suggested that autocrine signalling of ATP contributed by the opening of connexin and pannexin hemichannels in response to mechanical stress in VSMCs. Treatment of non-selective hemichannel inhibitor carbenoxolone significantly attenuated the accumulation of ATP and its hydrolysis by-product inorganic pyrophosphate (PP
i)
[47]. Additionally, a class of integral membrane proteins known as ATP-binding cassette (ABC) transporters has been reported to play a functional role in releasing ATP
[48][49]. Interestingly, these transporters are involved in regulating vascular tone in a cAMP/PKA-dependent vasorelaxation in VSMCs
[50]. These findings provide a potential conduit for extracellular ATP accumulation targeting the VSMC purinergic receptors.
Uniquely, ATP possesses a dual phenotype-dependent effect on VSMCs
[51][52]. ATP causes VSMCs to shift from a contractile into a proliferative phenotype in a concentration-dependent manner. A low concentration of ATP stimulates serum response factor (SRF), which enhances the expression of contractile specific proteins, smooth muscle 22 (SM22), and α-smooth muscle actin (αSMA). On the contrary, higher extracellular ATP concentration inhibits SRF activity and the specific contractile proteins, leading to the conversion of VSMCs into a synthetic phenotype
[53]. Moreover, this phenotype shift is accompanied by the downregulation of the P2X1 receptor and the upregulation of mitogenic P2Y1, P2Y2, and P2Y6 receptors
[54][55][56][57]. Continual release of ATP in response to high shear stress rapidly desensitized the P2X1 receptor, blunted its expression, and substantially promoted vascular wall relaxation prior to vascular remodelling via activation of mitogenic Gq-protein-coupled P2Y receptors
[58][59] (
Table 1). Hogarth et al. later proposed the downstream mechanism where ATP-induced P2Y receptors provoke a transient activation of the cAMP-PKA pathway, yielding an inhibitory effect on SRF activity
[60].
5. Vascular Endothelial Cells
The inner cellular lining of arteries, veins, and capillaries comprises a monolayer of endothelial cells (ECs). The vascular endothelium directly interacts with the circulating blood and is considered a barrier between the blood and the vessel wall. In such an arrangement, ECs are exposed to the mechanical force generated by flowing blood (shear stress), which can exert significant autocrine, paracrine, and endocrine actions influencing VSMCs, platelets, peripheral leucocytes, and circulating RBCs
[61]. The dynamic role of ECs in the vascular system is depicted by the involvement in the synthesis of vasodilator factors (NO and prostacyclin)
[62][63], vasoconstricting factors (angiotensin-converting enzyme (ACE), endothelin (ET), and free radicals)
[64], inflammatory mediators (interleukins (ILs) and major histocompatibility complex (MHC))
[65], and growth factors (insulin-like growth factor (IGF) and transforming growth factor (TGF))
[66]. In addition to these mediators, EC-released ATP under shear stress is mediated by the influx of extracellular Ca
2+ via P2X4 receptors
[67][68].
Purinergic receptors are widely distributed in the vascular system, and endothelial cells express multiple receptor subtypes, indicating their physiological and pathophysiological importance. There are several mechanisms involving ATP release channels in ECs, including caveolin-1 (Cav-1)
[69], volume-regulated anion channels (VRAC)
[70], and connexin hemichannels
[71]. Interestingly, shear stress evoked an increase in intracellular Ca
2+ where the release of ATP is localized. Yamamoto’s group revealed that the ATP release from ECs always preceded the Ca
2+ increase
[69]. This is supported by the action of ATP-activated purinergic receptors, which contribute to elevated intercellular Ca
2+ levels via P2X4 and P2Y1, 2, 4, 6-coupled Gq-PLC pathways
[67][72][73]. In this cellular context, the cytosolic pool of Ca
2+ under shear stress leads to endothelial nitric oxide synthase (eNOS)-NO-mediated vasodilation (
Table 1). Although NO production depends on Ca
2+ level, an additional mechanism of eNOS phosphorylation by PKA, protein kinase B (PKB), and cyclic guanosine monophosphate (cGMP)-dependent protein kinase II (cGKII) may compensate for NO production in the event of intercellular Ca
2+ reduction
[74][75]. Disruptions of the regulation of these channels contributed to vasoconstriction.
6. Circulating Red Blood Cells
The release of cytosolic ATP from circulating red blood cells (RBCs) is reflected in the microenvironment, such as under the hypoxic condition
[76], mechanical deformation
[77], shear stress
[78], and upon immune adherence clearance mediated by ligation of complement receptor 1 (CR1) on RBCs
[79]. Throughout the decades, the mechanism of ATP release in RBCs has been revealed via several channels. A membrane-bound nucleoside transporter of RBCs is the earliest channel reported to export ATP under hypercapnic conditions
[80]. Subsequent studies by Sprague’s group revealed the involvement of cystic fibrosis transmembrane conductance regulator (CFTR)-dependent adenylyl cyclase-cAMP pathway
[81][82]. The same group further demonstrated that activation of CFTR and pannexin-1 hemichannel contributed to ATP release
[83][84], which was supported by other works following RBCs’ deformation
[85][86]. Independently, activation of the cAMP-PKA pathway promotes oligomerization of voltage-dependent anion channel (VDAC) with the translocase protein TSPO2 and nucleotide transporter that transiently accumulate extracellular ATP up to 1-2 µM within a few minutes
[87].
Like other cells in the cardiovascular system, purinergic receptors, particularly P2 receptors involved in ATP-mediated signalling, are abundantly distributed in the RBCs
[88]. Quantitative PCR of human RBCs by Wang et al. revealed the expression level of P2 receptors in ascending order as follows: P2Y1/P2Y4/P2Y6/P2Y11/P2Y12 < P2X1/P2X4, P2X7/P2Y2 < P2Y13
[89]. From a teleological perspective, the non-physiological release of ATP may contribute to adaptive or maladaptive responses. For instance, bacterial toxin mediates autocrine signalling of ATP to act on P2X1 and P2X7, promoting phosphatidylserine (PS) exposure on RBCs that leads to cell shrinkage
[90]. Furthermore, activation of the complement system in the innate immune response exacerbates the ATP-P2X-mediated hemolysis, for which the downstream mechanism remains to be elucidated
[91]. Regardless, the ramification of ATP roles on P2X activation poses a high risk of blood-related diseases, including anemia, leukemia, or autoimmunity. On the other hand, the functional role of ATP on purinergic signalling has been revealed by several studies on P2Y receptors. Several studies demonstrated the involvement of P2Y1 receptors in malarial parasite development. Autocrine activation of P2Y1 by ATP induces an osmolyte permeability pathway in human and murine RBCs, providing sufficient nutrients for the erythrocytic cycle of the parasites
[92][93] (
Table 1).
Interestingly, higher expression of P2Y13 in human RBCs was revealed to negatively regulate ATP release from these cells. Wang and group depicted that the metabolism of ATP to ADP, which act on P2Y13 receptors, impairs the release of ATP via the inhibition of cAMP
[89]. As mentioned earlier, this inhibition may blunt the opening of CFTR and VDAC, which are cAMP-dependent ATP release channels. Moreover, paracrine signalling of ATP release from RBCs stimulates the P2 receptor on the vascular endothelium, which can promote endothelium-dependent and smooth-muscle-dependent vasodilation via the generation of vasodilators and anti-inflammatory factors such as nitric oxide (NO) and prostacyclin (PGI2)
[94]. Additionally, NO also inhibits hypoxia-induced ATP release from RBCs
[95].