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Endocrinology Vol. 142, No. 11 4693-4700
Copyright © 2001 by The Endocrine Society


ARTICLES

GATA4 Mediates Activation of the B-Type Natriuretic Peptide Gene Expression in Response to Hemodynamic Stress

Minna Marttila, Nina Hautala, Pierre Paradis, Miklos Toth, Olli Vuolteenaho, Mona Nemer and Heikki Ruskoaho

Departments of Pharmacology and Toxicology (M.M., N.H., M.T., H.R.) and Physiology (O.V.), Biocenter Oulu, University of Oulu, FIN-90014 University of Oulu, Finland; and Clinical Research Institute of Montreal (P.P., M.N.), University of Montréal, Montréal H2W 1R7, Canada

Address all correspondence and requests for reprints to: Heikki Ruskoaho, M.D., Ph.D., Department of Pharmacology and Toxicology, Faculty of Medicine, University of Oulu, P.O. Box 5000, FIN-90014 University of Oulu, Finland. E-mail: heikki.ruskoaho{at}oulu.fi


    Abstract
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
To identify the mechanisms that couple hemodynamic stress to alterations in cardiac gene expression, DNA constructs containing the rat B-type natriuretic peptide (BNP) promoter were injected into the myocardium of rats, which underwent bilateral nephrectomy or were sham-operated. Ventricular BNP mRNA levels were induced about 4-fold; and the BNP reporter construct containing the proximal 2200 bp, 5-fold, in response to 1-d nephrectomy. Deletion of sequences between bp -2200 and -114 did not affect basal or inducible activity of the BNP promoter. An activator protein-1-like site and two tandem GATA elements are located within this 114-bp sequence. Both deletion and mutation of the AP-1-like motif decreased basal activity but did not abolish the response to nephrectomy. In contrast, mutation or deletion of -90 bp GATA-sites abrogated the response to hemodynamic stress. The importance of these GATA elements to BNP promoter activation was further confirmed by the corresponding 38-bp oligonucleotide conferring hemodynamic stress responsiveness to a minimal BNP promoter. In gel mobility shift assays, nephrectomy increased left ventricular BNP GATA4 binding activity significantly. In conclusion, GATA elements are necessary and sufficient to confer transcriptional activation of BNP gene in response to hemodynamic stress.


    Introduction
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
HEMODYNAMIC OVERLOAD, a combination of mechanical, humoral and neural factors, plays a key role in the pathogenesis of cardiac disorders, including those arising from hypertension and congestive heart failure (1). At the genetic level, hemodynamic stress is accompanied by a transient increase in the cardiac expression of the immediate early response genes, reexpression of several fetal cardiac genes such as ß-myosin heavy chain (ß-MHC), and skeletal muscle {alpha}-actin as well as the induction of atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP) gene expression in the ventricle (2, 3, 4, 5). In normal adult heart, BNP is produced by both atria and ventricles (6, 7). The induction of BNP gene expression is one of the earliest cardiac myocyte-specific markers of hemodynamic overload; indeed, cardiac BNP mRNA and protein are increased rapidly at the onset of hemodynamic stress well before the development of left ventricular hypertrophy (8, 9, 10).

Because it is not possible to model in vitro the complex hemodynamic and neurohumoral stimuli that are associated with hemodynamic overload in vivo, little is known with respect to nuclear signaling involved in initiating or maintaining the response to the hemodynamic stress in the adult heart (11, 12, 13, 14). Ayogi and Izumo (15) demonstrated that injected c-fos promoter is regulated by pressure overload stimulus in the perfused rat heart preparation and that the pressure response element coincides with a serum response element. In addition, an activator protein-1 (AP-1)-like element has been reported to be responsible for conferring pressure overload responsiveness to the ANP promoter (16, 17), although this result is controversial (18, 19). Previous study has also demonstrated the importance of upstream stimulatory factor 1 binding to an E-box motif as an important transcription factor in the regulation of hemodynamic mediated changes in {alpha}-MHC gene (20). Furthermore, recent work has suggested that GATA binding sites seem to be required for activation of ß-MHC (19) and angiotensin II type 1a (AT1a) receptor (21) expression in response to pressure-overload hypertrophy in rats. Whether these changes are coupled to increased blood pressure or ventricular hypertrophy is not clearly established.

In the present study, we used the approach of DNA injection (22) into the myocardium to identify a cis element within the BNP promoter that mediates rapid response to a hemodynamic stress stimulus produced by bilateral nephrectomy in the intact adult rat heart. Nephrectomy is a complex hemodynamic stimulus, producing volume and pressure overload as well as neurohumoral activation, including tissue renin-angiotensin system (23, 24, 25). The BNP promoter is particularly well suited for these studies because, unlike c-fos (which is also expressed in nonmuscular cells), BNP is a cardiac myocyte-specific marker (6) that is rapidly induced by hemodynamic stress at the transcriptional level (26). Our results show that the GATA elements are necessary and sufficient to confer hemodynamic stress responsiveness of the BNP gene.


    Materials and Methods
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Plasmids
Rat BNP-luciferase plasmids, containing various BNP promoter fragments, were obtained by subcloning appropriate 5' deletions of the BNP promoter in the pXP-2 vector, as described by Grepin et al. (27). All deletions and mutations were confirmed by sequencing.

In vivo gene transfer
The 10- to 12-wk-old male Sprague Dawley rats were anesthetized with 250 µg/kg medetomidine hydrochloride, and 50 mg/kg ketamine hydrochloride ip. Plasmids in 0.9% NaCl were injected directly into the left ventricular free wall close to the apex under direct visualization by using a 100-µl Hamilton precision syringe (22). The injection vol was 100 µl, based on the previously published studies in various rat models (15, 22). The heart was then repositioned in the chest, the rats were briefly hyperventilated, and the incision was closed. Surgical and postoperative mortality was approximately 5% in all groups. At the time of death, the injection site appeared to be normal cardiac tissue with no fibrotic or necrotic signs. At the precise site of injection, a small light spot could be noted. To ensure reliable measurements of luciferase activities of the short deletion and mutation promoter constructs 1 wk after the injection, plasmid DNA consisted of 50–100 µg of the reported construct driven by the promoter of interest and 100 µg of a ß-galactosidase expression vector (pSVß-gal, Promega Corp., San Diego, CA) to correct for variation in transfection efficiency. Because of the concern that there might be competition among promoters for transcription factors (22), these dosages were chosen based on preliminary experiments showing that the amount of luciferase activity in cardiac homogenates increases dose-dependently after injection of a constant 100 µl vol containing 10–100 µg of plasmids. For p-2200BNPluc construct, luciferase activities were as follows: 10 µg, 12.5 ± 2.5 light units; 25 µg, 21.7 ± 3.8 light units; and 100 µg, 76.7 ± 7.6 light units (n = 8–9). Furthermore, in the animals subjected to nephrectomy and injected with 10 µg p-2200BNPluc, the fold increase of luciferase activity was similar to that after injection of 100 µg of the same plasmid (data not shown). Samples in which luciferase activity was less than 1.0 (background averaged 0.1–0.2), the injection failed, and values were not reported. The variation of the transfection efficiency estimated by different level of activities was less than 10%. The experimental design was approved by the Animal Use and Care Committee of the University of Oulu.

Induction of hemodynamic stress
On the sixth day after injection, the rats were anesthetized with fentanyl citrate (0.26 mg/kg), fluanisone (8.25 mg/kg), midazolam (4.1 mg/kg ip), and subjected to either bilateral nephrectomy or sham operation. Nephrectomy was accomplished by tying a 3-0 silk suture securely around the porta renalis containing the artery, the vein, and the ureter. In sham-operated animals, the kidneys were exposed, but no ligature was placed.

Blood pressure monitoring
Rats were anesthetized with 250 µg/kg medetomidine hydrochloride and 50 mg/kg ketamine hydrochloride ip, and instrumented with a catheter in the descending aorta coupled with a sensor and transmitter (TA11PA-C40; Data Sciences, St. Paul, MN) for telemetric monitoring of blood pressure. Blood pressure and heart rate were measured every 10 min and averaged every 6 h. On the sixth day after implantation, the rats were subjected to either bilateral nephrectomy or sham operation, as described above.

Tissue preparation
Rats were decapitated 7 d after injection of plasmid constructs (6, 12, or 26–28 h post nephrectomy). The basal one-third of the left ventricle was homogenized in 1 ml homogenization buffer (20 mM Tris-acetate, pH 7.5, 5 mM EDTA, 20 mM KCl, 2 mM Mg-acetate, and 0.5 mM dithiothreitol) with an Ultra-Turrax T25-tissue homogenizer (Janke und Kunkel, Stauffen, Germany). Homogenates were centrifuged at 6000 x g for 10 min at +4 C, and the supernatants were divided into two samples. Luciferase samples were kept in room temperature, and samples for ß-galactosidase assay were frozen at -20 C for subsequent analysis.

Reporter gene assays
Both luciferase and ß-galactosidase activities were assayed in the same supernatant of left ventricular homogenates. Using a luminometer (model RS, Labsystems Luminoskan, Helsinki, Finland), luciferase activity was measured in 20-µl aliquots (2.0–2.5% of the total volume) of the supernatant, using commercially available Luciferase Assay System (Promega Corp.). ß-Galactosidase activity was assayed in 20-µl samples of the supernatant, using commercially available Luminescent ß-galactosidase Detection Kit II (CLONTECH Laboratories, Inc., Palo Alto, CA).

Gel mobility shift assays
Nuclear extracts were prepared from ventricular tissue of sham-operated or nephrectomized rats as described by Deryckere and Gannon (28). Protein concentration was determined using the Bio-Rad Laboratories, Inc. Protein Assay, and aliquots were frozen at -70 degree C until use. Double-stranded synthetic oligonucleotides containing GATA (5'-TGTGTCT GATAAATCAGAGATAACCCCACC-3') motifs of the rat BNP promoter were labeled with [{alpha}-32P]dCTP. Binding reactions contained 30 µg crude nuclear extract and 2 µg poly-(dI-dC).(dI-dC) in a buffer containing 10 mM HEPES (pH 7.9), 1 mM MgCl2, 50 mM KCl, 1 mM dithiothreitol, 0.1 mM EDTA, 10% glycerol, 0.025% NP-40, 0.25 mM PMSF, and 1 µmM of each aprotinin, leupeptin and pepstatin, and when appropriate, various molar excesses of unlabeled double-stranded oligonucleotides. Reactions were carried out at room temperature for 20 min, and protein-DNA complexes were separated by electrophoresis on 5% polyacrylamide gel in 0.5x Tris-borate-EDTA buffer at +4 C. Nonlabeled double-stranded oligonucleotides corresponding to GATA binding sites of the BNP promoter and a GATA consensus sequence (Santa Cruz Biotechnology, Inc., Santa Cruz, CA) were used as specific competitor DNAs. Nonspecific competitor DNAs included a double-stranded oligonucleotide carrying the mutated binding site for GATA4 (5'-TGTGTCTGGTAAATCAGAGGTAACCCCACC-3') and Oct-1 as nonrelated DNA. To confirm that each reaction contained the equal amount of nuclear protein, the labeled Oct-1 oligonucleotide probe was used. For supershift experiments, 1 µg goat polyclonal GATA4, GATA5, or GATA6 affinity-purified IgG (Santa Cruz Biotechnology, Inc.) were used.

Histology
Hearts were washed and stopped in diastole by perfusion with PBS containing 50 mM KCl and then fixed by perfusion with Bouin solution (29). Specimens were embedded in paraffin and cut into 5-µm sections for immunostaining with rabbit polyclonal anti-GATA4 antibody (streptavidin/biotin immunoperoxidase method) as described previously (29).

Isolation and analysis of RNA
Total RNA was isolated from left ventricles by the guanidine thiocyanate-CsCl method (30). For the RNA Northern blot analysis, 20-µg samples of the RNA from the left ventricles were separated by electrophoresis on agarose gel and transferred to nylon membranes. A 390-bp fragment of rat BNP cDNA (31), cDNA probes for rat GATA4 (1417 bp) and GATA6 (1175 bp) made by the RT-PCR technique, and a full-length cDNA probe complementary to rat glyceraldehyde-3-phosphate-dehydrogenase (GAPDH) were labeled (32), and the membranes were hybridized and washed as described previously (10).

BNP RIA
The BNP RIA was performed as previously described (10). The sensitivity of the assay was 2 fmol/tube, and 50% displacements of the respective standard curve occurred at 25 fmol/tube. The intra- and interassay variations were less than 10% and 15%, respectively.

Statistics
Values are mean ± SEM. For the comparison of statistical significance between two groups, t test was used. A P value less than 0.05 was considered statistically significant.


    Results
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
BNP promoter elements required for basal gene expression in the adult heart
Seven days after injection, the BNP reporter construct containing 2200 bp upstream of the transcription initiation site was expressed in ventricular cells, and deletion of sequences between bp -2200 and -114 did not affect the activity of the BNP-luciferase vector (Fig. 1Go). This -114 bp fragment contains two major cis-acting elements, an AP-1-like element and a GATA motif (27, 33). Deletion of the AP-1-like element (construct -100 bp to +75 bp) decreased promoter activity over 10-fold, and deletion of the distal GATA motifs (construct -76 bp to +75 bp) reduced promoter activity further by 4-fold (1.7% of -2200 bp construct promoter activity, Fig. 1Go). Mutation of the AP-1-like element reduced BNP expression to 32%, and mutation of both GATA motifs at -90 bp decreased BNP expression to 57% of BNP-114 bp construct. The contribution of the GATA box at -90 bp to the ventricular-specific activity of the BNP promoter was further confirmed by the fact that a 38-bp oligonucleotide containing this GATA motif displayed transcriptional activity (2.1% of BNP-2200luc construct) when inserted upstream of the minimal BNP -60 promoter (Fig. 1Go). The mean activity of shortest construct (at light units) was about 10-fold higher than that of the promoterless background vector and was within the linear range of the luminometer (data not shown).



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Figure 1. Analysis of the transcriptional activities of rat BNP promoter sequences in the adult rat left ventricles. Basal transcriptional activity, as indicated by the relative ratios of luc/ß-gal activities 7 d after coinjection of 50–100 µg of each luciferase construct and 100 µg pSVß-gal into the left ventricles. Data are presented as mean ± SEM, with the activity of the -2200 bp BNP promoter set at 100%. The number of experiments in each group was 6–18. Luc, luciferase; A, an AP-1-like sequence; GG, two repeated GATA motifs at bp -90; •, AP-1-like element mutated; ••, GATA sites mutated.

 
Characterization of hemodynamic overload model
Bilateral nephrectomy raised mean arterial pressure from 107 ± 2 to 150 ± 4 mm Hg (n = 6, P < 0.001), and this increase in blood pressure was associated with a significant decrease in heart rate (from 370 ± 8 to 265 ± 10 beats/min, n = 6, P < 0.001). Both mean arterial pressure (110 ± 4 vs. 109 ± 3 mm Hg, n = 6) and heart rate (353 ± 10 vs. 343 ± 9 beats/min, n = 6) remained unchanged in the sham-operated animals. Nephrectomized rats also showed clear signs of volume overload, i.e. pulmonary edema and peritoneal ascites. BNP mRNA levels were 3.9-fold (P < 0.001) higher in the left ventricles of nephrectomized (when compared with sham-operated) animals (Fig. 2BGo). Also, endogenous ANP mRNA levels were 2.2-fold higher in nephrectomized rats than in sham-operated rats (P < 0.001, data not shown). The increase in ventricular BNP mRNA levels was accompanied with a significant increase in immunoreactive BNP levels in the left ventricle (15.9 ± 1.3 fmol/mg vs. 8.9 ± 0.8 fmol/mg, P < 0.001), and there was a tendency for plasma immunoreactive BNP levels to be higher in nephrectomized rats than in sham-operated rats (24.3 ± 3.7 fM vs. 13.2 ± 2.6 fM, NS). The index of ventricular hypertrophy, ventricular weight to body weight ratio, was equal in sham-operated and nephrectomized rats (3.73 ± 0.09 mg/g, n = 6 vs. 3.69 ± 0.08 mg/g, n = 6).



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Figure 2. A, Northern blot analysis of BNP, GATA4, and GATA6 mRNA levels in left ventricles of sham-operated (SHAM) and nephrectomized (NX) rats. Hybridization with GAPDH indicates the similar amount of total RNA on each lane. B, A bar graph showing BNP, GATA4, and GATA6 mRNA levels in left ventricles of sham-operated and nephrectomized rats. Open columns, Sham-operated rats (n = 8); closed columns, nephrectomized rats (n = 8). Data are presented as mean ± SEM, with the mean value of the sham group set as 1.0. ***, P < 0.001 vs. sham-operated rats (t test).

 
Transactivation of a -2200 bp BNP promoter by hemodynamic stress
To determine whether hemodynamic stress stimulates the transcription of the BNP gene, the expression of a luciferase reporter gene driven by 2200 bp of rat BNP 5' flanking sequences in sham-operated and hemodynamically overloaded rat ventricles was evaluated. In the animals injected with p-2200BNPluc, the mean ratio of luciferase activity to pSVßluc was 5.1-fold higher in the ventricles of animals subjected to nephrectomy, as compared with sham operation (P < 0.001, Fig. 3Go). The expression level of pSVß-galactosidase was similar in the left ventricles of sham-operated and nephrectomized animals (7.1 ± 0.5 U/ml vs. 8.3 ± 0.5 U/ml), showing that increases in the expression of p-2200BNPluc are attributable to augmentation of the transcriptional activity of the BNP promoter sequences. The effect was sequence-specific, as illustrated by the absence of hemodynamic stress-stimulated increases in transcription directed by the proximal ANP promoter (p-135ANPluc, data not shown).



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Figure 3. Analysis of the transcriptional activities of rat BNP promoter sequences in the rat left ventricles in response to hemodynamic stress. Inducible transcriptional activity, as indicated by the relative ratios of luc/ß-gal activities 7 d after coinjection of 50–100 µg of each luciferase construct and 100 µg pSVß-gal into the left ventricles of rats subjected to sham operation (open columns) or nephrectomy (closed columns) on d 6. Data are presented as mean ± SEM, with the mean value of the sham group for each construct set as 1.0. ***, P < 0.001; **, P < 0.01; *, P < 0.05 vs. sham-operated rats (t test).mut, Mutation.

 
To evaluate the time course of the induction of BNP transcription after acute hemodynamic overload, the BNP promoter activities were analyzed also at 6 and 12 h after nephrectomy. Nephrectomy for 12 h produced a 1.7-fold (from 1.11 ± 0.19 to 1.87 ± 0.30 U, P < 0.05) increase in the activity of -2200 bp BNP construct, but no inducible expression was noted at 6 h post nephrectomy (1.51 ± 0.32 vs. 1.74 ± 0.38 U).

GATA motif is essential for hemodynamic stress induction of the BNP gene
To identify which DNA sequences mediate hemodynamic overload-stimulated increases in BNP transcription, the ability of nested 5' deletions to respond to nephrectomy was evaluated. The 114-bp fragment of rat BNP promoter was shown to be sufficient for inducible expression in hemodynamic stress, because deletion to -114 bp resulted in no significant decrease in inducibility in response to nephrectomy (Fig. 3Go). In fact, p-114BNPluc showed the highest level of inducibility (7.2-fold) among the constructs tested. Hemodynamic stress significantly increased (over 5-fold) the expression of the -114 bp constructs containing mutation or deletion of the AP-1-like element. In contrast, mutation of both GATA motifs at -90 bp, as well as deletion of the -90 GATA-sites (construct -76 bp to +75 bp), resulted in almost complete loss of inducible expression (Fig. 3Go). The contribution of the GATA box at -90 bp to the inducible expression of the BNP promoter was confirmed by using a 38-bp oligonucleotide containing this site, inserted upstream of the minimal BNP -60 promoter. Hemodynamic stress significantly (3.5-fold, P = 0.013) increased the expression of this construct similarly to that exhibited by the longest -2200 bp BNP-luciferase construct (Fig. 3Go).

Hemodynamic stress up-regulates left ventricular GATA binding activity
Gel mobility shift assays were used to analyze the DNA-binding activities that interact with the GATA motifs of the BNP promoter (Fig. 4Go). When left ventricular nuclear extracts were incubated with the 30-bp double-stranded oligonucleotide containing the -90 BNP GATA sites, a specific complex was obtained (Fig. 4AGo, lane 2). To determine the specificity of ventricular GATA binding activity, competition analyses were performed. The formation of complexes with the rBNP-90 GATA probe was effectively inhibited by the unlabeled self (Fig. 4AGo, lanes 3 and 4) and GATA consensus DNA (Fig. 4AGo, lanes 7 and 8), indicating that the DNA-protein complex was the result of a specific interaction. The binding was unaffected by an excess of oligonucleotides corresponding to the nonrelated competitor DNA Oct-1 (Fig. 4AGo, lane 5) or the mutated BNP GATA site (Fig. 4AGo, lane 6). To confirm further that the complex bound to the BNP GATA site contains GATA proteins, supershift assays were carried out by using GATA4 (Fig. 4B, lanes 2 and 6), GATA5 (Fig. 4BGo, lanes 3 and 7), and GATA6 (Fig. 4BGo, lanes 4 and 8) antibodies. Experiments in which ventricular extracts from sham-operated or nephrectomized rats were used clearly showed antibody-induced supershift of GATA4 but not GATA5 or GATA6 complexes. Bilateral nephrectomy for 26–28 h produced a 1.93-fold increase (P < 0.01) in BNP GATA binding activity (Fig. 4CGo). At 6 and 12 h post nephrectomy, there was a tendency for BNP GATA binding activity to increase, but these changes (1.33- and 1.35-fold, respectively, data not shown) were not statistically significant.



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Figure 4. A, Competition gel mobility shift analysis of rat left ventricular nuclear extracts. Nuclear extracts of the nephrectomized rat hearts were incubated with radiolabeled rBNP-90 GATA oligonucleotide probe (lane 2). The binding reaction was incubated with 50- (lane 3) or 10-fold (lane 4) molar excess of unlabeled rBNP-90 GATA DNA, 50-fold molar excess of each nonrelated DNA Oct-1 (lane 5), BNP/mutGATA double-stranded DNA (lane 6), and with 50- (lane 7) or 10-fold (lane 8) molar excess of GATA consensus DNA. Lane 1 contains no extract. B, Supershift reactions were performed by incubating the binding reactions with 1 µg goat polyclonal GATA4 (lanes 2 and 6), GATA5 (lanes 3 and 7), or GATA6 IgG (lanes 4 and 8). Similar results were obtained from three independent experiments. NX, nephrectomy; N.S., nonspecific binding; Ab, antibody. C, Effect of nephrectomy on left ventricular BNP GATA binding activity. SHAM, Sham-operated rats (n = 6); NX, nephrectomized rats (n = 6). Data are mean ± SEM. *, P < 0.01 vs. SHAM (t test).

 
GATA4 and GATA6 mRNA levels and immunohistochemistry
Finally, we examined the possibility that the increase in GATA binding activity could result from an increase in the expression of GATA4 gene itself or an increase in GATA4 protein. Northern blot analysis with both rat GATA4 and GATA6 probes identified a single 3.3-kb and 1.8-kb mRNA species, respectively, in the ventricles of adult rats. Bilateral nephrectomy had no effect on left ventricular GATA4 or GATA6 mRNA levels (Fig. 2Go). There was no observable difference in GATA4 immunoreactivity between the ventricles of the nephrectomized and control rats as assessed by immunohistochemical staining (data not shown).


    Discussion
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Hemodynamic overload leads to cardiac hypertrophy and ultimately to deterioration of cardiac contractile function, but the nuclear events that are activated by hemodynamic stress and initiate the hypertrophic genetic program are not known. In the present study, we used the rat BNP promoter, because its 5' flanking sequences have been well characterized in in vitro transfection studies (27, 33, 34, 35). Also, BNP gene expression is rapidly activated in response to hemodynamic stress in vivo (9, 10), in contrast to many contractile protein genes that are activated later during hypertrophic process (1, 2, 3). Our in vivo results show that the proximal 114 bp are sufficient for basal ventricular-specific expression of the BNP gene, in agreement with previous in vitro results (27) demonstrating that in transient transfection assays of cultured neonatal rat ventricular cells, the 114-bp fragment of rat BNP promoter is sufficient for maximal cardiac BNP gene expression. Interestingly, the 114-bp fragment of rat BNP promoter also retained full hemodynamic stress responsiveness. Although this finding does not exclude the existence of hemodynamic stress responsive sequences (positive or negative) elsewhere in the rat BNP gene, our results show that -114 bp sequences are sufficient for mediating both basal and hemodynamic stress-stimulated transcription of the BNP gene.

The typical response to hemodynamic stress is the rapid activation of the immediate early gene c-fos (3, 36). This results in the accumulation of c-fos protein, which interacts with Jun family members to constitute AP-1 activity (37). The AP-1-like element is highly conserved across species in the BNP gene (27). Mutation of the AP-1-like element decreased BNP promoter activity; and when the AP-1-like site was deleted, basal promoter activity was reduced over 10-fold. In vitro results with nested 5' deletions at bp -100 have previously shown about 4-fold decrease in BNP promoter activity (27); thus, both in vitro and in vivo results indicate a role for this site in basal transcription. However, mutation or deletion of the AP-1-like motif had no significant effect on the hemodynamic stress-induced increase in BNP promoter activity. This result is different from those obtained with ANP promoter by von Harsdorf et al. (17), who studied the effects of aortic banding for 7 d in dogs injected with rat ANP reporter constructs. Site-specific mutation of the ANP AP-1-like element abrogated the response to pressure overload, showing that this site is necessary for the induction of the ANP gene (17). It has also been reported that the AP-1 site and CRE-site were sufficient to induce ANP promoter activity after acute elevation of cardiac wall stress (16). Although several factors may account for the divergent results, the data suggest that different transcriptional factors may regulate the induction of ANP and BNP genes in response to hemodynamic overload in the intact adult heart. The response of the two gene products to mechanical stretch is also different. Both in vitro and in vivo, ANP gene expression is unresponsive to short-term wall stretch, whereas BNP is rapidly activated (8, 9, 38).

A major finding of the present study was that the regulatory elements conferring induction of the BNP gene during hemodynamic overload map to the GATA motif. GATA4, -5, and -6, which are expressed in the developing heart (27, 39, 40, 41), play important roles in the transcriptional regulation of cardiac genes and heart morphogenesis (42, 43). Induction of GATA4 precedes expression of cardiac marker genes and appearance of beating cells (34). Moreover, inhibition of GATA4 expression with GATA4 antisense construct specifically blocked cardiac muscle gene expression (34, 35). In vitro, transfection studies have established that GATA4 is a potent activator of BNP (27), ANP (44, 45), cardiac troponin C (46), {alpha}-MHC (47), cardiac troponin I (48), and m2 muscarinic acetylcholine receptor (49). Mutation of GATA elements in {alpha}-MHC and myosin light chain decreases their transcriptional activities in vivo (47, 50). In agreement with these reports, mutation of GATA motifs located in the BNP promoter between positions -95 bp and -85 bp decreased promoter activity about 40%, showing that the GATA motif has a slight effect on basal ventricular-specific BNP gene expression. Furthermore, in vivo injection experiments showed that after mutating or deleting both proximal GATA-sites, the inducibility to nephrectomy was completely abolished. Finally, the GATA sequences were sufficient to convert a neutral promoter to one which is hemodynamic stress-responsive.

Recently, it has been shown that the GATA sequences are required for the induction of ß-MHC (19) and AT1a receptor expression (21) in response to pressure overload hypertrophy. In the latter study, the authors detected reproducible binding on AT1a GATA sites in extracts of hypertrophied (but not control) hearts (21), suggesting that GATA binding activity is enhanced in the hypertrophied myocardium. The present study extends those findings in demonstrating that left ventricular BNP GATA4, but not GATA5 and GATA6 binding, is activated at an early stage of hemodynamic overload, well before the development of left ventricular hypertrophy. Furthermore, no significant differences in the levels of GATA4 and GATA6 mRNA or GATA4 immunoreactivity were observed, suggesting that the increase in GATA binding activity may involve posttranslational mechanisms.

The present in vivo transfection experiments demonstrate that the rat GATA motif transduces the hemodynamic stress stimulus 26–28 h post nephrectomy. However, it is possible that other cis elements may also contribute to hemodynamic stress response. In vitro, other transcription factors, such as nuclear factor-{kappa}B (NF-{kappa}B) (51) and nuclear factor of activated T cells 3 (NF-AT3) (52), are also important for BNP gene expression, and recent work has suggested that ANP expression may be regulated by cooperative interaction of cis elements with GATA4 and Csx/Nkx2.5 (45). The potential interaction of these transcription factors with GATA4, in promoting the changes in cardiac gene expression in response to hemodynamic stress in the intact rat heart, remains to be studied.

In conclusion, our study demonstrates that acute hemodynamic stress produced by bilateral nephrectomy increases BNP reporter expression through a GATA4-dependent pathway. These results identify, for the first time, a tissue-specific pathway that is involved in the adaptive response of the adult heart to acute hemodynamic overload. Whether GATA4 mediates the cardiac response to other stimuli that induce both BNP gene expression and hypertrophy (such as angiotensin II, endothelin-1, or noradrenaline) remains to be tested, especially because bilateral nephrectomy induces neurohumoral activation (23, 24, 25).


    Acknowledgments
 
We thank Mrs. Sirpa Rutanen and Mrs. Tuula Inkala for expert technical assistance.


    Footnotes
 
This work was supported by grants from the Academy of Finland, Sigfrid Juselius Foundation, Finnish Foundation for Cardiovascular Research, and the Medical Research Council of Canada (to M.N.).

Abbreviations: ANP, Atrial natriuretic peptide; AP-1, activator protein-1; BNP, B-type natriuretic peptide; GAPDH, glyceraldehyde-3-phosphate-dehydrogenase; MHC, myosin heavy chain; NF-AT3, nuclear factor of activated T cells 3; NF-{kappa}B, nuclear factor {kappa}B.

Received April 2, 2001.

Accepted for publication July 12, 2001.


    References
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Lorell BH, Carabello BA 2000 Left ventricular hypertrophy. Pathogenesis, detection, and prognosis. Circulation 470–479
  2. Chien KR, Zhu H, Knowlton KU, Miller-Hance W, van-Bilsen M, O’Brien TX, Evans SM 1993 Transcriptional regulation during cardiac growth and development. Annu Rev Physiol 55:77–95[CrossRef][Medline]
  3. Sadoshima J, Izumo S 1997 The cellular and molecular response of cardiac myocytes to mechanical stress. Annu Rev Physiol 59:551–571[CrossRef][Medline]
  4. Ruskoaho H 1992 Atrial natriuretic peptide: synthesis, release, and metabolism. Pharmacol Rev 44:479–602[Medline]
  5. de Bold AJ, Bruneau BG, Kuroski de Bold ML 1996 Mechanical and neuroendocrine regulation of the endocrine heart. Cardiovasc Res 31:7–18[CrossRef][Medline]
  6. Dagnino L, Drouin J, Nemer M 1991 Differential expression of natriuretic peptide genes in cardiac and extracardiac tissues. Mol Endocrinol l5:1292–1300
  7. Argentin S, Ardati A, Tremblay S, Lihrmann I, Robitaille L, Drouin J, Nemer M 1994 Developmental stage-specific regulation of atrial natriuretic factor gene transcription in cardiac cells. Mol Cell Biol 14:777–790[Abstract/Free Full Text]
  8. Mäntymaa P, Vuolteenaho O, Marttila M, Ruskoaho H 1993 Atrial stretch induces rapid increase in brain natriuretic peptide but not in atrial natriuretic peptide gene expression in vitro. Endocrinology 133:1470–1473[Abstract]
  9. Magga J, Marttila M, Mäntymaa P, Vuolteenaho O, Ruskoaho H 1994 Brain natriuretic peptide in plasma, atria, and ventricles of vasopressin- and phenylephrine-infused conscious rats. Endocrinology 134:2505–2515[Abstract]
  10. Magga J, Vuolteenaho O, Marttila M, Ruskoaho H 1997 Endothelin-1 is involved in stretch-induced early activation of BNP gene expression in atrial but not in ventricular myocytes: acute effects of mixed ETA/ETB and AT1 receptor antagonists in vivo and in vitro. Circulation 96:3053–3062[Abstract/Free Full Text]
  11. Molkentin JD, Olson EN 1997 GATA4: a novel transcriptional regulator of cardiac hypertrophy. Circulation 96:3833–3835
  12. Olson EN, Molkentin JD 1999 Prevention of cardiac hypertrophy by calcineurin inhibition. Hope or hype? Circ Res 84:623–632[Free Full Text]
  13. Sugden PH 1999 Signaling in myocardial hypertrophy. Life after calcineurin? Circ Res 84:633–646[Free Full Text]
  14. Hunter JJ, Chien KR 1999 Signaling pathways for cardiac hypertrophy and failure. N Engl J Med 341:1276–1283[Free Full Text]
  15. Aoyagi T, Izumo S 1993 Mapping of the pressure element of the c-fos gene by direct DNA injection into beating hearts. J Biol Chem 268:27176–27179[Abstract/Free Full Text]
  16. Cornelius T, Holmer SR, Muller FU, Riegger GA, Schunkert H 1997 Regulation of the rat atrial natriuretic peptide gene after acute imposition of left ventricular pressure overload. Hypertension 30:1348–1355[Abstract/Free Full Text]
  17. von Harsdorf R, Edwards JG, Shen Y, Kudej RK, Dietz R, Leinwand LA, Nadal-Ginard B, Vatner SF 1997 Identification of a cis-acting regulatory element conferring inducibility of the atrial natriuretic factor gene in acute pressure overload. J Clin Invest 100:1294–1304[Medline]
  18. Knowlton KU, Rockman HA, Itani M, Vovan A, Seidman CE, Chien KR 1995 Divergent pathways mediate the induction of ANF transgenes in neonatal and hypertrophic ventricular myocardium. J Clin Invest 96:1311–1318
  19. Hasegawa K, Lee SJ, Jobe SM, Markham BE, Kitsis RN 1997 cis-Acting sequences that mediate induction of the ß-myosin heavy chain gene expression during left ventricular hypertrophy due to aortic constriction. Circulation 96:3943–3953[Abstract/Free Full Text]
  20. Xiao Q, Ojamaa K 1998 Regulation of cardiac {alpha}-myosin heavy chain gene transcription by a contractile-responsive E-box binding protein. J Mol Cell Cardiol 30:87–95[CrossRef][Medline]
  21. Herzig TC, Jobe SM, Aoki H, Molkentin JD, Cowley Jr AW, Izumo S, Markham BE 1997 Angiotensin II type 1a receptor gene expression in the heart: AP-1 and GATA-4 participate in the response to pressure overload. Proc Natl Acad Sci USA 94:7543–7548[Abstract/Free Full Text]
  22. Kass-Eisler A, Leinwand L 1997 DNA- and adenovirus-mediated gene transfer into cardiac muscle. Methods Cell Biol 52:423–437[Medline]
  23. Volpe M, Gigante B, Enea I, Porcellini A, Russo R, Lee MA, Magri P, Condorelli G, Savoia C, Lindpaintner K, Rubattu S 1997 Role of tissue renin in the regulation of aldosterone biosynthesis in the adrenal cortex of nephrectomized rats. Circ Res 81:857–864[Abstract/Free Full Text]
  24. Katz SA, Opsahl JA, Lunzer MM, Forbis LM, Hirsch AT 1997 Effect of bilateral nephrectomy on active renin, angiotensinogen, and renin glycoforms in plasma and myocardium. Hypertension 30:259–266[Abstract/Free Full Text]
  25. Leenen FH, Skarda V, Yuan B, White R 1999 Changes in cardiac ANG II postmyocardial infarction in rats: effects of nephrectomy and ACE inhibitors. Am J Physiol 276:H317–H325
  26. Magga J, Vuolteenaho O, Tokola H, Marttila M, Ruskoaho H 1997 Involvement of transcriptional and posttranscriptional mechanisms in cardiac overload-induced increase in of B-type natriuretic peptide gene expression. Circ Res 81:694–702[Abstract/Free Full Text]
  27. Grepin C, Dagnino L, Robitaille L, Haberstroh L, Antakly T, Nemer M 1994 A hormone-encoding gene identifies a pathway for cardiac but not skeletal muscle gene transcription. Mol Cell Biol 14:3115–3129[Abstract/Free Full Text]
  28. Deryckere F, Gannon F 1994 A one-hour minipreparation technique for extraction of DNA-binding proteins from animal tissues. Biotechniques 16:405[Medline]
  29. Paradis P, Dali-Youcef N, Paradis FW, Thibault G, Nemer M 2000 Overexpression of angiotensin II type I receptor in cardiomyocytes induces cardiac hypertrophy and remodeling. Proc Natl Acad Sci USA 97:931–936[Abstract/Free Full Text]
  30. Chirgwin JM, Przybyla AE, MacDonald RJ, Rutter WJ 1979 Isolation of biologically active ribonucleic acid from sources enriched in ribonuclease. Biochemistry 18:5294–5299[CrossRef][Medline]
  31. Ogawa Y, Nakao K, Mukoyama M, Hosoda K, Shirakami G, Arai H, Saito Y, Suga S, Jougasaki M, Imura H 1991 Natriuretic peptides as cardiac hormones in normotensive and spontaneously hypertensive rats. The ventricle is a major site of synthesis and secretion of brain natriuretic peptide. Circ Res 69:491–500[Abstract/Free Full Text]
  32. Fort P, Marty L, Piechaczyk M, el Sabrouty S, Dani C, Jeanteur P, Blanchard JM 1985 Various rat adult tissues express only one major mRNA species from the glyceraldehyde-3-phosphate-dehydrogenase multigenic family. Nucleic Acids Res 13:1431–1442[Abstract/Free Full Text]
  33. Thuerauf DJ, Hanford DS, Glembotski CC 1994 Regulation of rat brain natriuretic peptide transcription. A potential role for GATA-related transcription factors in myocardial cell gene expression. J Biol Chem 269:17772–17775[Abstract/Free Full Text]
  34. Grepin C, Robitaille L, Antakly T, Nemer M 1995 Inhibition of transcription factor GATA-4 expression blocks in vitro cardiac muscle differentiation. Mol Cell Biol 15:4095–4102[Abstract]
  35. Grépin C, Nemer G, Nemer M 1997 Enhanced cardiogenesis in embryonic stem cells overexpressing the GATA-4 transcription factor. Development 124: 2387–2395
  36. Komuro I, Yazaki Y 1993 Control of cardiac gene expression by mechanical stress. Annu Rev Physiol.55:55–75
  37. Karin M 1995 The regulation of AP-1 activity by mitogen-activated protein kinases. J Biol Chem 270:16483–16456[Free Full Text]
  38. Marttila M, Vuolteenaho O, Ganten D, Nakao K, Ruskoaho H 1996 Synthesis and secretion of natriuretic peptides in the hypertensive TGR(mREN-2)27 transgenic rat. Hypertension 28:995–1004[Abstract/Free Full Text]
  39. Laverriere AC, MacNeill C, Mueller C, Poelmann RE, Burch JB, Evans T 1994 GATA-4/5/6, a subfamily of three transcription factors transcribed in developing heart and gut. J Biol Chem 269:23177–23184[Abstract/Free Full Text]
  40. Jiang YM, Evans T 1996 The Xenopus GATA-4/5/6 genes are associated with cardiac specification and can regulate cardiac-specific transcription during embryogenesis. Dev Biol 174: 258–270
  41. Heikinheimo M, Scandrett JM, Wilson DB 1994 Localization of transcription factor GATA-4 to regions of the mouse embryo involved in cardiac development. Dev Biol 164:361–373[CrossRef][Medline]
  42. Evans T 1997 Regulation of cardiac gene expression by GATA-4,5. Trends Cardiovasc Med 7:75–83[CrossRef]
  43. Durocher D, Nemer M 1998 Combinatorial interactions regulating cardiac transcription. Dev Genet 22:250–262[CrossRef][Medline]
  44. Durocher D, Chen CY, Ardati A, Schwartz RJ, Nemer M 1996 The atrial natriuretic factor promoter is a downstream target for Nkx-2.5 in the myocardium. Mol Cell Biol 16:4648–4655[Abstract]
  45. Durocher D, Charron F, Warren R, Schwartz RJ, Nemer M 1997 The cardiac transcription factors Nkx2–5 and GATA-4 are mutual cofactors. EMBO J 16:5687–5696[CrossRef][Medline]
  46. Ip HS, Wilson DB, Heikinheimo M, Tang Z, et al. 1994 The GATA-4 transcription factor transactivates the cardiac muscle-specific troponin C promoter-enhancer in nonmuscle cells. Mol Cell Biol 14:7517–7526[Abstract/Free Full Text]
  47. Molkentin JD, Kalvakolanu DV, Markham BE 1994 Transcription factor GATA-4 regulates cardiac muscle-specific expression of the {alpha}-myosin heavy-chain gene. Mol Cell Biol 14:4947–4957[Abstract/Free Full Text]
  48. Murphy AM, Thompson WR, Peng LF, Jones L 1997 Regulation of the rat cardiac troponin I gene by the transcription factor GATA-4. Biochem J 322:393–401
  49. Rosoff ML, Nathanson NM 1998 GATA factor-dependent regulation of cardiac m2 muscarinic acetylcholine gene transcription. J Biol Chem 273:9124–9129[Abstract/Free Full Text]
  50. McGrew MJ, Bogdanova N, Hasegawa K, Hughes SH, Kitsis RN, Rosenthal N 1996 Distinct gene expression patterns in skeletal and cardiac muscle are dependent on common regulatory sequences in the MLC1/3 locus. Mol Cell Biol 16:4524–4538[Abstract]
  51. Liang F, Gardner DG 1999 Mechanical strain activates BNP gene transcription through a p38/NF-kB-dependent mechanism. J Clin Invest 104:1603–1612[Medline]
  52. Molkentin JD, Lu J-R, Antos CL, Markham B, Richardson J, Robbins J, Grant SR, Olson EN 1998 A calcineurin-dependent transcriptional pathway for cardiac hypertrophy. Cell 93:215–228[CrossRef][Medline]



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