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Protamine reversal of anticoagulation achieved with a low molecular weight heparin. The effects on eicosanoids, clotting and complement factors.

Hemodynamic and hematologic effects of protamine reversal of low molecular weight heparin (LMWH) anticoagulation with and without protamine pretreatment, as well as reversal of anticoagulation with unfractionated standard heparin (SH), were studied in canine subjects. Protamine reversal caused less severe thrombocytopenia in the two LMWH groups compared to SH animals, while neutropenia occurred equally in all groups. Cl-esterase inhibitor levels were minimally increased, whereas C3 levels and leucotriene levels were unaltered. TxB2 and 6-keto-PGF1 alpha increased during protamine reversal of LMWH anticoagulation. TCT and APTT were affected less with LMWH than SH anticoagulation. Anti-Xa levels increased with anticoagulation in all animals, but protamine did not reverse the elevated anti-Xa levels in LMWH anticoagulated dogs to the same degree as occurred with SH anticoagulation. TCT, APTT and bleeding times were normalized by protamine in all animals. Protamine reversal of LMWH anticoagulation with or without protamine pretreatment did not reveal any clear differences in eicosanoids or complement factors compared to SH anticoagulation, although differences in anti-Xa activity clearly separated these two heparins.

Animals↗

A method for the quantitation of protamine in plasma.

A unique and simple colorimetric method for the quantitation of plasma protamine levels has been developed. The method is established on the competitive binding displacement mechanism between protamine and heparin-azure A dye complex, and the metachromatic color change of azure A dye in the presence of heparin. Because the method is based on the clinical specificity of protamine as the heparin antagonist, it is specific for protamine quantitation. Plasma protamine levels determined by this method are within 94% of accuracy when compared with their aqueous counterparts determined by the conventional Lowry protein assay. Since the method measures the protamine excess after heparin neutralization, it potentially could be employed during clinical heparin reversal with protamine to monitor protamine excess. In addition, the method may provide a useful means to identify the mechanism of the so-called "heparin rebound".

Azure Stains↗

At high heparin concentrations, protamine concentrations which reverse heparin anticoagulant effects are insufficient to reverse heparin anti-platelet effects.

Combined effects of heparin and protamine on plasma clot structure and platelet function were studied. Anticoagulant effects were monitored as changes in aPTT. Clot structure was defined in terms of fibrin fiber mass/length ratio (mu) and clot elastic modulus (EM). Platelet function was studied utilizing platelet aggregation and platelet force development (PFD) measurements. Heparin (1 U/ml) prolonged the aPTT from 30 to > 300 seconds, reduced PFD from 5,100 to 0 dynes, decreased mu (in batroxobin-induced gels) from 1.36 to 1.08 x 10(13) daltons/cm and decreased clot EM from 9,600 to 2000 dynes/cm2. Varying amounts of protamine reversed these effects: 16 micrograms/ml normalized the aPTT, 20 micrograms/ml normalized PFD, 32 micrograms/ml corrected mu, and 20 micrograms/ml returned EM to baseline. At high heparin concentrations (4 U/ml), protamine concentrations which corrected anticoagulant effects were inadequate to reverse antiplatelet effects. A protamine concentration of 40 micrograms/ml normalized the aPTT and mu, but 140 micrograms/ml of protamine was required to reverse heparin suppression of force development and clot elastic modulus. Excess protamine inhibited clotting and platelet function. In plasma containing 1 u heparin/ml, 140 micrograms protamine/ml reduced PFD by 83%, prolonged the aPTT by 63%, and reduced clot EM by 75%. In heparin free plasma, > 75 micrograms protamine/ml prolonged the aPTT. Thus, platelet function and clot structure are sensitive to protamine during heparin neutralization, and anti-platelet effects of heparin may persist when the aPTT is completely corrected. Excess protamine inhibits platelet function and compromises clot structure.

Blood Coagulation↗

Identification of the binding site of two monoclonal antibodies to human protamine.

We have previously developed a number of monoclonal antibodies (Mabs) that bind to protamine. One of these antibodies, Hup1N, binds to human protamine 1 but not to protamine 2. In contrast, Mab HupA binds both protamine 1 and protamine 2. The epitopes for these two Mabs were observed to overlap, and were localized to the evolutionarily conservative amino-terminal region of protamine 1. This assignment is based on antibody binding to protamine from different species in which the protamine sequence is known, as well as analysis of antibody binding to synthetic peptides and synthetic peptides with specific amino acid substitutions.

Amino Acid Sequence↗

Primary structures of two protamine 2 variants (St2a and St2b) from stallion spermatozoa.

Protamines were extracted from stallion sperm cell nuclei, alkylated with iodoacetamide and separated by reversed-phase high-performance liquid chromatography. Two main components, protamine 1 and protamine 2, were obtained. The latter contains two subspecies, separable by acetic acid-urea-polyacrylamide gel electrophoresis. The primary structure of protamine 2a (St2a) was determined by analysis of fragments obtained from purified protamine 2 peak by thermolysin digestion. The digested peptides were separated by acetic acid-urea gel electrophoresis and, after electroblotting onto a polyvinylidene difluoride filter, their amino acid sequences were determined by pulse liquid peptide sequencing. The amino acid sequence of protamine 2b was predicted from the double sequence data of protamine 2 peak by eliminating the amino acid of St2a in each cycle. St2a and St2b were found to contain 62 and 58 amino acid residues, respectively, and they seem to be homologous with type 2 protamines from human and mouse spermatozoa.

Alkylation↗

Calculating the protamine-heparin reversal ratio: a pilot study investigating a new method.

There is no consensus as to the dosage of protamine required to reverse a given dose of heparin. The amounts advised vary widely. The hypothesis was investigated that doses of protamine smaller than those usually recommended could be used following cardiac surgery to successfully reverse heparin activity as measured by the activated coagulation time (ACT). A group of 18 patients scheduled for cardiopulmonary bypass (CPB) were investigated with their informed consent. A baseline ACT was measured before anticoagulation with heparin. At the end of CPB, an initial neutralizing dose (IND) of protamine (2 mg/kg) was administered. The ACT was measured after 5 minutes and a further dose of protamine (2 mg/kg) was then administered to make up the full dose. The heparin activity (HA) before and after the IND of protamine reversal was calculated according to the method described by Bull. The IND of protamine (2 mg/kg) was expressed as a ratio of the change in HA (the latter also expressed as mg/kg). The average +/- standard deviation (SD) preoperative ACT was 155 +/- 21 seconds with a range of 130 to 199 seconds. Following heparin administration the ACT increased to 701 +/- 152 seconds. After the IND of protamine, the average ACT of 160 +/- 31 (range, 121 to 250) was not statistically (NS) significantly different from the starting value. A further dose of 2 mg/kg of protamine ("full-dose") decreased (NS) the ACT only minimally to an average of 151 +/- 18 (range, 128 to 206) seconds.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Relationship between granulocyte elastase and C3a under protamine dosing in on-pump cardiac surgery.

OBJECTIVE: The complement cascade and granulocytes are activated in on-pump cardiac surgery. If activation of complement directly regulates granulocytes, granulocyte elastase (GEL) should increase significantly after protamine administration. We examined the effect of protamine on granulocytes by protamine administration and observation of the effect on GEL and C3a. METHODS: Thirty patients who underwent coronary artery bypass grafting were randomly assigned to two groups. In 15 patients, protamine was administered 5 min after the termination of cardiopulmonary bypass, and was administered 35 min after cardiopulmonary bypass in the other 15 patients. All patients were perfused with heparin-coated circuits and received 300 IU/kg heparin and 3 mg/kg protamine. GEL and C3a concentrations were measured at 7 time points. RESULTS: GEL concentrations increased significantly just before aortic declamping and did not increase significantly after protamine administration. C3a concentrations, however, did not increase during cardiopulmonary bypass and did increase significantly after protamine administration. CONCLUSIONS: This study indicates that GEL does not increase after protamine administration and that complement concentration does not directly affect GEL release.

Aged↗

Can extra protamine eliminate heparin rebound following cardiopulmonary bypass surgery?

OBJECTIVES: Heparin rebound, the reappearance of anticoagulant activity after adequate neutralization with protamine, is thought to contribute to excessive postoperative bleeding after cardiac surgery. We have previously demonstrated that a significant amount of heparin is bound nonspecifically to plasma proteins and is incompletely neutralized by protamine. The aim of this study was to investigate whether clinically important bleeding attributable to heparin rebound can be eliminated by infusion of small amounts of additional protamine for 6 hours postoperatively and whether this treatment can reduce mediastinal blood loss. METHODS: Three hundred patients undergoing elective cardiac surgery were randomized to receive either a continuous infusion of protamine sulphate (25 mg/h for 6 hours) postoperatively or saline placebo. Serial blood samples were obtained to measure thrombin clotting time and anti-factor Xa activity. Heparin bound nonspecifically to plasma proteins was measured after displacement with a chemically altered heparin with low affinity to antithrombin. Mediastinal blood loss and transfusion requirements were recorded. RESULTS: Heparin rebound was demonstrated in every patient in the placebo group as reflected by increased thrombin clotting time, anti-factor Xa activity, and protein-bound heparin between 1 and 6 hours after surgery. In contrast, heparin rebound was eliminated in the protamine infusion group. The thrombin clotting time was normalized and both heparin concentration and protein-bound heparin were almost undetectable (P <.001). There was a modest 13% reduction in postoperative bleeding but this did not reduce blood transfusions. No adverse events were attributable to the extra protamine. CONCLUSIONS: Postoperative protamine infusion was able to almost totally abolish heparin rebound. In the context of this study, protamine infusion resulted in reduced postoperative bleeding but the magnitude was insufficient to alter transfusion requirements.

Anticoagulants↗

Protamine induces vasorelaxation of human internal thoracic artery by endothelial NO-synthase pathway.

BACKGROUND: Protamine is commonly used in cardiac surgery to reverse the anticoagulant effects of heparin. We investigated the role of different nitric oxide synthase pathways in the response of the human internal thoracic artery to protamine and evaluated whether heparin could prevent this effect. METHODS: A tension-recording method was used to obtain baseline measurements of contractions of human internal thoracic artery rings achieved with norepinephrine. Isolated internal thoracic artery rings were suspended in two organ chambers. One contained Krebs-Henseleit solution and served as control. The other contained a heparin or Nomega-Nitro-L-arginine (L-NAM, an inhibitor of both endothelial and inducible nitric oxide synthase) or a specific inhibitor of inducible nitric oxide synthase, aminoguanidine. Increasing doses of protamine were added to both chambers and dose-response curves were obtained. RESULTS: Protamine was found to relax contracted internal thoracic arteries 56% +/- 4.7% of baseline measurements in a concentration-dependent manner. When L-NAM was added, protamine caused only a slight decrease of tension. There were no differences in the relaxing effect of protamine in the presence of aminoguanidine or heparin. CONCLUSIONS: Protamine induces nitric oxide-dependent relaxation of the internal thoracic artery by activation of endothelial nitric oxide synthase pathway. Heparin could not prevent this relaxing effect of protamine.

Coronary Artery Bypass↗

Rapid disappearance of protamine in adults undergoing cardiac operation with cardiopulmonary bypass.

BACKGROUND: Despite long use of protamine in cardiac operations, neither protamine concentrations nor pharmacokinetics have been reported in patients. METHODS: Twenty-eight patients (age, 26 to 80 years) undergoing various cardiac surgical procedures gave their consent to receive 250 mg of protamine sulfate administered intravenously by an infusion pump during 5 minutes. Protamine was administered at the usual intraoperative time after separation from cardiopulmonary bypass for reversal of heparin. Timed arterial blood samples were obtained after protamine infusion. Blood plasma was subjected to solid-phase extraction and high-performance liquid chromatography. Total (free + heparin-bound) protamine concentration versus time data were subjected to pharmacokinetic modeling. RESULTS: Twenty-six patients completed the study. Total plasma protamine concentrations declined rapidly. Model-independent pharmacokinetic analysis revealed median (range) values as follows: volume of distribution, 5.4 L (0.82 to 34 L); clearance, 1.4 L/min (0.61 to 3.8 L/min); and half-life, 4.5 min (1.9 to 18 min). Schwarz-Bayesian criterion identified a two-compartment exponential model with adjustment for weight in the central compartment volume of distribution as performing better than other compartmental or Michaelis-Menten models. CONCLUSIONS: Protamine has a very short (approximately 5 minutes) half-life after a single 250-mg dose in adult patients. This short half-life could underlie recurrent anticoagulation after initial apparent reversal of heparin.

Aged↗

Comparison of the cardiovascular effects of intravenous and intraaortic protamine in the conscious and anesthetized dog.

Controversy exists as to whether intraaortic (IA) administration of protamine sulfate has less adverse effects than the intravenous (IV) route. The effect of protamine on contractility is not well established. Therefore, 9 dogs underwent chronic instrumentation to monitor aortic pressure (AP), left ventricular (LV) pressure, central venous pressure, cardiac index (CI), heart rate, stroke volume index (SVI), systemic vascular resistance index, and LV volume. The end-systolic LV pressure-volume relationship was used as a load-independent measure of contractility. Each dog was administered IV and IA protamine on separate occasions after pretreatment with heparin. Studies were performed with and without anesthesia. In the awake studies, analysis of variance showed greater decreases in mean AP (p less than .03), CI (p less than .05), and SVI (p less than .02) with IA protamine infusion. In the anesthetized animals, there were no significant differences between IA and IV administration of protamine. Protamine did not decrease contractility in any group. We conclude that IA administration of protamine offers no advantage over IV administration in the dog. Protamine does not decrease contractility when given by either route.

Analysis of Variance↗

Complement activation by heparin-protamine complexes during cardiopulmonary bypass: effect of C4A null allele.

OBJECTIVES: The first objective was to determine the effect of inherited differences in the classic pathway complement protein C4 on complement activation by heparin-protamine complexes in cardiac surgery. Specifically, we hypothesized that patients with heterozygous C4A null phenotype (A0BB), who have decreased amounts of C4A, may have increased complement activation because of reduced clearance of heparin-protamine complexes. The second objective was to determine whether heparin-protamine-induced complement activation correlated with postoperative pulmonary shunt fractions. METHODS: C4 typing was performed by agarose gel immunofixation and crossed immunoelectrophoresis. Complement activation was measured by radioimmunoassay of C3a and C4a before cardiopulmonary bypass, after bypass, and after protamine infusion. Shunt fractions were calculated from blood gases. RESULTS: Of the 79 patients, 18 expressed heterozygous C4A null allele (A0BB), 16 had heterozygous C4B null allele (AAB0), three had homozygous C4B null alleles (AA00), and the rest expressed both C4A and C4B alleles (AABB). Patients with heterozygous C4A null allele had significantly increased plasma levels of C4a after protamine neutralization of heparin (C4a of 2862 +/- 375 ng/ml; mean +/- standard error of the mean) when compared with patients with normal expression of C4 alleles (AABB) (C4a of 1580 +/- 141 ng/ml) or heterozygous C4B null allele (C4a 1526 +/- 208 ng/ml). Pulmonary shunt fractions obtained after the operation correlated with the classic pathway complement activation by heparin-protamine complexes, but not with alternative pathway complement activation during cardiopulmonary bypass. CONCLUSIONS: Patients with heterozygous C4A null phenotype have increased complement activation by heparin-protamine complexes during cardiac operations, possibly because of their defective clearance. The classic pathway complement activation by heparin-protamine interaction correlates with postoperative pulmonary shunt fractions.

Alleles↗

Facilitated protamine transfer at polarized water/1,2-dichloroethane interfaces studied by cyclic voltammetry and chronoamperometry at micropipet electrodes.

Cyclic voltammetry and chronoamperometry at micropipet electrodes were applied to study the phase transfer of polypeptide protamine facilitated by complexation with charged ionophore dinonylnaphthalenesulfonate (DNNS) at polarized water/1,2-dichloroethane (DCE) interfaces, i.e., sDNNS(-) (DCE) + protamine(n+) (aq) right harpoon over left harpoon protamine-DNNS complex (DCE). Well-defined current responses based on the selective protamine transfer were obtained reproducibly even in the presence of 0.12 M NaCl. The selective and reproducible responses make this voltammetric/amperometric approach an attractive alternative to the traditional potentiometric counterpart based on mixed potential responses, for which both protamine and Na(+) need to be transferred simultaneously. Using both organic- and water-filled micropipet electrodes, the reaction mechanism was studied under different mass-transfer conditions controlled by diffusion of protamine, DNNS, and the complex in the outer solution of the pipets. Both charge number of transferred protamine, n, and complexation stoichiometry, s, were determined to be approximately 20 by chronoamperometry. With these parameters, the electrochemically irreversible voltammograms were analyzed by assuming a one-step transfer model to obtain experimental transfer coefficients, which represent apparent dependence of the transfer rate on the interfacial potential. The analysis showed that the transfer coefficients are much larger or smaller than a normal value of approximately 0.5 and strongly depend on the diffusion-limiting species, i.e., 0.088 +/- 0.005, 0.89 +/- 0.01, and 0.065 +/- 0.008 for protamine, DNNS, and the complex, respectively. The apparently anomalous transfer coefficients were explained consistently by a phenomenological model based on adsorption and transfer processes.

Electrochemistry↗

Protamine sulfate enhances lipid-mediated gene transfer.

A polycationic peptide, protamine sulfate, USP, has been shown to be able to condense plasmid DNA efficiently for delivery into several different types of cells in vitro by several different types of cationic liposomes. The monovalent cationic liposomal formulations (DC-Chol and lipofectin) exhibited increased transfection activities comparable to that seen with the multivalent cationic liposome formulation, lipofectamine. This suggests that lipofectamine's superior in vitro activity arises from its ability to condense DNA efficiently and that protamine's primary role is that of a condensation agent, although it also possesses several amino acid sequences resembling that of a nuclear localization signal. While the use of polycations to condense DNA has been previously reported, the of protamine sulfate, USP as a condensation agent was found to be superior to poly-L-lysine as well as to various other types of protamine. These differences among various salt forms of protamine appear to be attributable to structural differences between the protamines and not due to differences in the net charge of the molecule. The appearance of lysine residues within the protamine molecule correlate with a reduction in binding affinity to plasmid DNA as well as an observed loss in transfection enhancing activity. This finding sheds light on the structural requirements of condensation agents for use in gene transfer protocols. Furthermore, protamine sulfate, USP is an FDA-approved compound with a documented safety profile and could be readily used as an adjuvant to a human gene therapy protocol.

Amino Acid Sequence↗

A simple procedure for the isolation and purification of protamine messenger ribonucleic acid from trout testis.

Preparation of milligram quantities of purified poly(A)+ (polyadenylated) protamine mRNA from trout testis tissue was accomplished by a simple procedure using gentle conditions. This involves chromatography of the total nucleic acids isolated by dissociation of polyribosomes with 25 mM-EDTA to release messenger ribonucleoprotein particles and deproteinization of the total postmitochondrial supernatant with 0.5% sodium dodecyl sulphate in 0.25 M-NaCl by binding it to a DEAE-cellulose column. Total RNA was bound under these conditions, and low-molecular-weight RNA, lacking 18S and 28S RNA, could be eluted with 0.5 M-NaCl and chromatographed on oligo(dT)-cellulose columns to select for poly(A)+ RNA. Further purification of both the unbound poly(A)- RNA and the bound poly(A)+ mRNA on sucrose density gradients showed that both 18S and 28S rRNA were absent, being removed during the DEAE-cellulose chromatography step. Poly(A)- RNA sedimented in the 4S region whereas the bound poly(A)+ RNA fraction showed a main peak at 6S [poly(A+) protamine mRNA] and a shoulder in the 3-4S region. Analysis of the main peak and the shoulder on a second gradient showed that most of the main peak sedimented at 6S, whereas the shoulder sedimented slower than 4S. The identity of the poly(A)+ protamine mRNA was established by the following criteria: (1) purified protamine mRNA migrated as a set of four bands on urea/polyacrylamide-gel electrophoresis; (2) analysis of the polypeptides synthesized in the wheat-germ extract by starch-gel electrophoresis showed a single band of radioactivity which co-migrated exactly with the carrier trout testis protamine standard; and (3) chromatography of the polypeptide products on CM-cellulose (CM-52) showed the presence of three or four radioactively labelled protamine components that were co-eluted with the unlabelled trout testis protamine components added as carrier. The availability of large quantities of purified protamine mRNA should now permit a more thorough analysis of its physical and chemical properties.

Animals↗

The ulcer healing effect of protamine sulphate in rat stomach.

BACKGROUND: Protamine sulphate has been reported to stimulate nitric oxide production from blood vessels, which is a pivotal factor for gastric ulcer healing. Our preliminary study also showed that protamine sulphate potentiated the ulcer healing effect of heparin. METHODS: Male SD rats with acetic acid-induced gastric ulcers were given protamine sulphate (40-80 mg/kg, s.c.) twice daily for 4 or 7 days. L-NG-nitroarginine methyl ester (L-NAME, 5 mg/kg), an inhibitor of nitric oxide synthase (NOS), was given s.c. prior to protamine sulphate (80 mg/kg) treatment. Ulcer healing, angiogenesis, mucosal histological changes, NOS activity and growth factors were determined. RESULTS: Protamine sulphate dose-dependently accelerated gastric ulcer healing, which was accompanied by a significant increase in angiogenesis, mucosal regeneration and constitutive NOS activity. Inhibition of gastric secretion was observed. Epidermal growth factor (EGF), basic fibroblast growth factor (bFGF), tumour necrosis factor-alpha (TNF-alpha) or inducible NOS activity was also affected. L-NAME completely blocked the beneficial effects of protamine sulphate. CONCLUSIONS: Protamine sulphate accelerates gastric ulcer healing through a mucosal nitric oxide-dependent and possibly also the EGF-and bFGF-associated pathways, which are followed by an increase of angiogenesis and mucosal regeneration. Acid inhibition contributes in part to the ulcer healing action of protamine sulphate.

Animals↗

The importance of aprotinin and pentoxifylline in preventing leukocyte sequestration and lung injury caused by protamine at the end of cardiopulmonary bypass surgery.

BACKGROUND: Protamine has adverse effects on pulmonary gas exchange during the postoperative period. The objective of this study was to investigate the importance of aprotinin and pentoxifylline in preventing the leukocyte sequestration and lung injury caused by protamine administered after the termination of cardiopulmonary bypass (CPB). METHODS: Participants (n = 39) were allocated into three groups at the termination of CPB: Group 1, (control group, n = 16); Group 2 (aprotinin group, n = 12), who received protamine + aprotinin (15,000 IU/kg); and Group 3 (Pentoxifylline group, n = 11), who received protamine + pentoxifylline (10 mg/kg). Leukocyte counts in pulmonary and radial arteries were determined after the termination of CPB and before any drug was given (t1), and 5 minutes (t2), 2 hours (t3), 6 hours (t4) and 12 hours (t5) after the administration of protamine. Alveolar-arterial O2 gradient (A-aO2) and dynamic pulmonary compliance were measured at t1, t2 and t3. RESULTS: In the control group, an increase in pulmonary leukocyte sequestration was observed 5 minutes and 2 hours after protamine administration, after which this difference disappeared. No significant degree of pulmonary sequestration was detected in any measurements after protamine was administered in the aprotinin and pentoxifylline (PTX) groups. Dynamic lung compliance was 50.1, 45.2 and 47.2 ml/cm H2O in the control group, 49.2, 61.1 and 56.3 ml/cm H2O in the aprotinin group, and 49.5, 54.5 and 50.4 ml/cm H2O in the PTX group. The A-aO2 gradient was 212.2, 263.3 and 254.3 mm Hg in the control group, 209.4, 257.1 and 217.3 mm Hg in the aprotinin group, and 211.3, 260.8 and 219.2 mm Hg in the PTX group. CONCLUSION: Aprotinin and PTX treatments have favourable effects on lung function by reducing protamine-induced leukocyte sequestration into lungs at the end of CPB.

Aged↗

Reversible block of the calcium release channel/ryanodine receptor by protamine, a heparin antidote.

Channel activity of the calcium release channel from skeletal muscle, ryanodine receptor type 1, was measured in the presence and absence of protamine sulfate on the cytoplasmic side of the channel. Single-channel activity was measured after incorporating channels into planar lipid bilayers. Optimally and suboptimally calcium-activated calcium release channels were inactivated by the application of protamine to the cytoplasmic side of the channel. Recovery of channel activity was not observed while protamine was present. The addition of protamine bound to agarose beads did not change channel activity, implying that the mechanism of action involves an interaction with the ryanodine receptor rather than changes in the bulk calcium concentration of the medium. The block of channel activity by protamine could be reversed either by removal by perfusion with buffer or by the addition of heparin to the cytoplasmic side of the channel. Microinjection of protamine into differentiated C(2)C(12) mouse muscle cells prevented caffeine-induced intracellular calcium release. The results suggest that protamine acts on the ryanodine receptor in a similar but opposite manner from heparin and that protamine can be used as a potent, reversible inhibitor of ryanodine receptor activity.

Animals↗