Activated Protein C Strengthens Cardiac Tolerance to Ischemic Insults in Aging

Circ Res. 2022 Jan 21;130(2):252-272. doi: 10.1161/CIRCRESAHA.121.319044. Epub 2021 Dec 21.


Background: APC (activated protein C) is a plasma serine protease with anticoagulant and anti-inflammatory activities. EPCR (Endothelial protein C receptor) is associated with APC's activity and mediates its downstream signaling events. APC exerts cardioprotective effects during ischemia and reperfusion (I/R). This study aims to characterize the role of the APC-EPCR axis in ischemic insults in aging.

Methods: Young (3-4 months) and aged (24-26 months) wild-type C57BL/6J mice, as well as EPCR point mutation (EPCRR84A/R84A) knockin C57BL/6J mice incapable of interaction with APC and its wild type of littermate C57BL/6J mice, were subjected to I/R. Wild-type APC, signaling-selective APC-2Cys, or anticoagulant-selective APC-E170A were administrated before reperfusion.

Results: The results demonstrated that cardiac I/R reduces APC activity, and the APC activity was impaired in the aged versus young hearts possibly attributable to the declined EPCR level with aging. Serum EPCR measurement showed that I/R triggered the shedding of membrane EPCR into circulation, while administration of APC attenuated the I/R-induced EPCR shedding in both young and aged hearts. Subsequent echocardiography showed that APC and APC-2Cys but not APC-E170A ameliorated cardiac dysfunction during I/R in both young and aged mice. Importantly, APC elevated the resistance of the aged heart to ischemic insults through stabilizing EPCR. However, all these cardioprotective effects of APC were blunted in the EPCRR84A/R84A mice versus its wild-type littermates. The ex vivo working heart and metabolomics results demonstrated that AMPK (AMP-activated protein kinase) mediates acute adaptive response while AKT (protein kinase B) is involved in chronic metabolic programming in the hearts with APC treatment.

Conclusions: I/R stress causes shedding of the membrane EPCR in the heart, and administration of APC prevents I/R-induced cardiac EPCR shedding that is critical for limiting cardiac damage in aging.

Keywords: aging; anticoagulants; protein C; reperfusion; serine proteases.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Aging / metabolism*
  • Animals
  • Cardiotonic Agents / therapeutic use
  • Endothelial Protein C Receptor / blood
  • Endothelial Protein C Receptor / metabolism*
  • Female
  • Heart / growth & development
  • Male
  • Mice
  • Mice, Inbred C57BL
  • Myocardial Reperfusion Injury / drug therapy
  • Myocardial Reperfusion Injury / metabolism*
  • Myocardium / metabolism
  • Protein C / metabolism*
  • Protein C / therapeutic use


  • Cardiotonic Agents
  • Endothelial Protein C Receptor
  • Protein C