Modulation by dietary salt of verapamil disposition in humans

BACKGROUND

The intestine is an increasingly well-recognized site of first-pass drug metabolism. In this study, we determined the influence of dietary salt on the steady-state disposition of verapamil, a drug that undergoes extensive first-pass metabolism.

METHODS AND RESULTS

Eight normal volunteers received 120 mg of racemic verapamil orally twice a day for 21 days. The disposition kinetics of verapamil enantiomers were determined after coadministration of intravenous deuterated verapamil with the morning oral dose on days 7, 14, and 21. Each study day was preceded by 7 days on a fixed-salt diet: in 5 subjects, the initial study was conducted during a low-salt (10 mEq/d) diet, the second study during a high-salt (400 mEq/d) diet, and the third during a low-salt diet, whereas in the other 3 subjects, the sequence of diets was reversed. Plasma concentrations of both unlabeled enantiomers (ie, from oral therapy) were significantly (P<0.05) lower during the high-salt phase (eg, mean area under the time-concentration curve [0 to 12 hours] for S-verapamil: 7765+/-2591 ng. min. mL-1 [high salt] versus 12 514+/-3527 ng. min. mL-1 [low salt], P<0.05). Peak plasma concentrations were significantly lower and the extent of PR interval prolongation significantly blunted with the high-salt diet. In contrast, data with labeled drug (ie, reflecting the intravenous route) were nearly identical for the 2 diets.

CONCLUSIONS

These data indicate that a clinically important component of presystemic drug disposition occurs at the prehepatic (presumably intestinal) level and is sensitive to dietary salt.

A K+ channel splice variant common in human heart lacks a C-terminal domain required for expression of rapidly activating delayed rectifier current

We have cloned HERG USO, a C-terminal splice variant of the human ether-à-go-go-related gene (HERG), the gene encoding the rapid component of the delayed rectifier (IKr), from human heart, and we find that its mRNA is approximately 2-fold more abundant than that for HERG1 (the originally described cDNA). After transfection of HERG USO in Ltk- cells, no current was observed. However, coexpression of HERG USO with HERG1 modified IKr by decreasing its amplitude, accelerating its activation, and shifting the voltage dependence of activation 8.8 mV negative. As with HERG USO, HERGDeltaC (a HERG1 construct lacking the C-terminal 462 amino acids) also produced no current in transfected cells. However, IKr was rescued by ligation of 104 amino acids from the C terminus of HERG1 to the C terminus of HERGDeltaC, indicating that the C terminus of HERG1 includes a domain (</=104 amino acids) that is critical for faithful recapitulation of IKr. The lack of this C-terminal domain not only explains the finding that HERG USO does not generate IKr but also indicates a similar mechanism for hitherto-uncharacterized long QT syndrome HERG mutations that disrupt the splice site or the C-terminal. We suggest that the amplitude and gating of cardiac IKr depends on expression of both HERG1 and HERG USO.

Abnormalities of the QT interval in primary disorders of autonomic failure

BACKGROUND

Experimental evidence shows that activation of the autonomic nervous system influences ventricular repolarization and, therefore, the QT interval on the ECG. To test the hypothesis that the QT interval is abnormal in autonomic dysfunction, we examined ECGs in patients with severe primary autonomic failure and in patients with congenital dopamine beta-hydroxylase (DbetaH) deficiency who are unable to synthesize norepinephrine and epinephrine.

SUBJECTS AND METHODS

Maximal QT and rate-corrected QT (QTc) intervals and adjusted QTc dispersion [(maximal QTc - minimum QTc on 12 lead ECG)/square root of the number of leads measured] were determined in blinded fashion from ECGs of 67 patients with primary autonomic failure (36 patients with multiple system atrophy [MSA], and 31 patients with pure autonomic failure [PAF]) and 17 age- and sex-matched healthy controls. ECGs of 5 patients with congenital DbetaH deficiency and 6 age- and sex-matched controls were also analyzed.

RESULTS

Patients with MSA and PAF had significantly prolonged maximum QTc intervals (492+/-58 ms(1/2) and 502+/-61 ms(1/2) [mean +/- SD]), respectively, compared with controls (450+/-18 ms(1/2), P < .05 and P < .01, respectively). A similar but not significant trend was observed for QT. QTc dispersion was also increased in MSA (40+/-20 ms(1/2), P < .05 vs controls) and PAF patients (32+/-19 ms(1/2), NS) compared with controls (21+/-5 ms(1/2)). In contrast, patients with congenital DbetaH deficiency did not have significantly different RR, QT, QTc intervals, or QTc dispersion when compared with controls.

CONCLUSIONS

Patients with primary autonomic failure who have combined parasympathetic and sympathetic failure have abnormally prolonged QT interval and increased QT dispersion. However, QT interval in patients with congenital DbetaH deficiency was not significantly different from controls. It is possible, therefore, that QT abnormalities in patients with primary autonomic failure are not solely caused by lesions of the sympathetic nervous system, and that the parasympathetic nervous system is likely to have a modulatory role in ventricular repolarization.

Cisapride-induced torsades de pointes

Two cases of torsades de pointes associated with cisapride are presented, both in association with concomitant drug therapy that inhibits cisapride biotransformation. In one case, plasma cisapride was elevated days after the event, strongly supporting a role for accumulation of the drug in causing the arrhythmia. It is emphasized that these adverse drug reactions are not idiosyncratic, but rather are predictable based on an understanding of the underlying mechanisms.

Modulation of cardiac Na+ current phenotype by beta1-subunit expression

Na+ current (INa) is smaller, activates and inactivates more slowly, and displays less negative voltage dependence of inactivation in the neonatal rat than in the adult rat. We have observed very similar changes when INa is recorded as a function of time in culture in mouse atrial tumor (AT-1) cells. The differences between mature and immature INa are reminiscent of those observed when skeletal muscle Na+ channel alpha subunits are expressed alone (immature) or with the beta1 subunit (mature). In the present experiments, we tested the hypothesis that suppression of beta1-subunit expression by antisense oligonucleotides would prevent the development of a mature INa. The mouse beta1 subunit was cloned from an AT-1 cDNA library and found to be identical to that in the rat at 216/218 amino acids. AT-1 cells exposed to anti-beta1 antisense oligonucleotides displayed an immature INa at day 8 in culture, whereas untreated cells or cells exposed to sense oligonucleotides displayed a mature INa. This result was observed with 2 different oligonucleotides, and neither affected the rapidly activating component of the delayed rectifier K+ current, another current recorded in AT-1 cells. These findings indicate that in these cells, the gating of INa is modulated by beta1 expression and that alpha-beta1 coexpression is required for the development of a mature cardiac INa phenotype.

Mechanisms and management of proarrhythmia

It is now well recognized that therapy with antiarrhythmic drugs can not only suppress cardiac arrhythmias, but also may increase their frequency or provoke new ones. Specific proarrhythmia syndromes, each with a distinct underlying mechanism and approach to therapy, have been described. The best-recognized examples are digitalis intoxication, proarrhythmia associated with sodium-channel block, and torsade de pointes occurring during QT-prolonging therapies. In the case of sodium-channel blockers, 2 forms of proarrhythmia are commonly recognized: slow atrial flutter with 1:1 atrioventricular conduction, and frequent ventricular tachycardia ([VT], most often found in patients with pre-existing VT reentrant circuits). In all cases, the best approach to therapy is to identify patients at risk (and thereby avoid therapy entirely), to recognize proarrhythmia when it occurs, to withdraw offending agent(s), and to use specific corrective therapies when available. Although most recognized episodes of proarrhythmia are thought to occur early in drug therapy, the increased mortality during chronic antiarrhythmic therapy demonstrated in large randomized trials suggests this phenomenon can also develop during long-term drug treatment. The recognition of proarrhythmia and the delineation of its underlying mechanisms should not only improve therapy with available drugs, but may also direct development of newer agents devoid of this potential.

The drug transporter P-glycoprotein limits oral absorption and brain entry of HIV-1 protease inhibitors

Currently available HIV-1 protease inhibitors are potent agents in the therapy of HIV-1 infection. However, limited oral absorption and variable tissue distribution, both of which are largely unexplained, complicate their use. We tested the hypothesis that P-glycoprotein is an important transporter for these agents. We studied the vectorial transport characteristics of indinavir, nelfinavir, and saquinavir in vitro using the model P-glycoprotein expressing cell lines L-MDR1 and Caco-2 cells, and in vivo after intravenous and oral administration of these agents to mice with a disrupted mdr1a gene. All three compounds were found to be transported by P-glycoprotein in vitro. After oral administration, plasma concentrations were elevated 2-5-fold in mdr1a (-/-) mice and with intravenous administration, brain concentrations were elevated 7-36-fold. These data demonstrate that P-glycoprotein limits the oral bioavailability and penetration of these agents into the brain. This raises the possibility that higher HIV-1 protease inhibitor concentrations may be obtained by targeted pharmacologic inhibition of P-glycoprotein transport activity.

Normalization of acquired QT prolongation in humans by intravenous potassium

BACKGROUND

QT interval prolongation and dispersion have been implicated in serious arrhythmias in congestive heart failure (CHF) and the congenital and drug-induced long-QT syndromes (LQTS). In a subset of the congenital LQTS, infusion of potassium can correct QT abnormalities, consistent with in vitro increases in outward currents such as I(Kr) or I(Kl) when extracellular potassium concentration ([K+]o) is increased. Furthermore, increasing [K+]o decreases the potency of I(Kr)-blocking drugs in vitro. The purpose of this study was to test the hypothesis that increasing [K+]o corrects QT abnormalities in CHF and in subjects treated with quinidine.

METHODS AND RESULTS

KCl (maximum, 40 mEq) was infused into (1) 12 healthy subjects treated with quinidine sulfate (5 doses of 300 mg/5 h) or placebo and (2) 8 CHF patients and age-matched normal control subjects. Mean [K+] increased from 4 to 4.2 mEq/L to 4.7 to 5.2 mEq/L. Potassium infusion significantly reversed QTUc prolongation, especially in the precordial leads (quinidine, 590+/-79 to 479+/-35 [+/-SD] ms(1/2), P<.001; CHF, 521+/-110 to 431+/-47 ms(1/2), P<.05). There was no effect in either control group. Similarly, potassium decreased QTUc dispersion (quinidine, 210+/-62 to 130+/-75 ms(1/2), P<.01; CHF, 132+/-68 to 84+/-35 ms(1/2), P=.07) and was without effect in the control subjects. QT morphological abnormalities, including U waves and bifid T waves, were reversed by potassium.

CONCLUSIONS

Potentially arrhythmogenic QT abnormalities during quinidine treatment and in CHF can be nearly normalized by modest elevation of serum potassium.

Structure and function of cardiac sodium and potassium channels

The application of patch-clamp and molecular approaches has resulted in an increasingly refined understanding of the molecular entities underlying cardiac sodium and potassium currents. The sodium current results from expression of a single large alpha-subunit, whereas multiple potassium currents and potassium channel alpha-subunits have been identified. Recapitulation of some ion currents in heterologous expression systems requires not only expression of alpha-subunits but also ancillary (beta) subunits. Domains common to functions such as activation, inactivation, and drug block are now being identified in alpha- and beta-gene products. Variability in the expression or function of individual ion-channel genes is an increasingly recognized source of variability in the ion currents recorded in heart cells under physiological conditions (e.g. during development) as well as in disease.

Rapid inactivation determines the rectification and [K+]o dependence of the rapid component of the delayed rectifier K+ current in cardiac cells

Two characteristic features of the rapid component of the cardiac delayed rectifier current (IKr) are prominent inward rectification and an unexpected reduction in activating current with decreased [K+]o. Similar features are observed with heterologous expression of HERG, the gene thought to encode the channel carrying IKr, moreover, recent studies indicate that the mechanism underlying rectification of HERG current is the inactivation that channels rapidly undergo during depolarizing pulses. The present studies were designed to determine the mechanism of IKr rectification and [K+]o sensitivity in the mouse atrial myocyte cell line, AT-1 cells. Reducing [Mg2+]i to 0, which reverses inward rectification of some K+ channels, did not alter IKr current-voltage relationships, although it did decrease sensitivity to the IKr blockers dofetilide and quinidine 2- to 5-fold. To determine the presence and extent of fast inactivation of IKr in AT-1 cells, a brief hyperpolarizing pulse (20 ms to -120 mV) was applied during long depolarizations. Immediately after this pulse, a very large outward current that decayed rapidly to the previous activating current baseline was observed. This outward current component was blocked by the IKr-specific inhibitor dofetilide, indicating that it represented recovery from fast inactivation during the hyperpolarizing step, with fast reinactivation during the return to depolarized potential. With removal of inactivation using this approach, current-voltage relationships for IKr ([K+]o, 1 to 20 mmol/L) were linar and reversed close to the predicted Nernst potential for K+. In addition, decreased [K+]o decreased the time constants for open-->inactivated and inactivated-->open transitions. Thus, in these cardiac myocytes, as with heterologously expressed HERG, IKr undergoes fast inactivation that determines its characteristic inward rectification. These studies demonstrate that the mechanism underlying decreased activating current observed at low [K+]o is more extensive fast inactivation.

Dietary salt increases first-pass elimination of oral quinidine

BACKGROUND

Some cytochrome P450 (CYP) enzymes, including CYP3A, are expressed not only in the liver but also in the intestine; the latter may therefore be an important site of drug disposition. Animal data suggests that dietary salt modulates expression of renal CYPs. We therefore hypothesized that intestinal CYP3A may be similarly modulated by dietary salt.

METHODS

The effect of changes in dietary salt on the disposition of two CYP3A substrates, quinidine (administered orally and intravenously) and 14C-erythromycin (administered intravenously) were determined after normal volunteers were given high-salt (400 mEq/day) and low-salt (10 mEq/day) diets for 7 to 10 days each.

RESULTS

Plasma concentrations after oral quinidine were significantly lower during the high-salt phase, with the difference between the two treatments attributable to changes within the first 1 to 4 hours after administration. For example, the area under the plasma concentration-time curve for the first hour after drug administration was 0.56 +/- 0.38 microgram.hr/ml for the high-salt diet compared with 1.57 +/- 0.60 micrograms.hr/ml for the low-salt diet (p < 0.05). Similarly, the peak plasma concentration (Cmax) achieved was lower and the time to reach Cmax was later for the high-salt diet (p < 0.05). In contrast, the terminal phase elimination half-lives were similar for the two diets, and no differences in disposition were found with the intravenous drug. The erythromycin breath test was unaffected by the dietary treatments.

CONCLUSIONS

These results indicate an effect of dietary salt on the presystemic disposition of orally administered quinidine. Although the mechanism(s) of CYP3A activity modulation is unknown, this finding may be important in determining drug availability in conditions associated with abnormal salt homeostasis.

Inhibition of cardiac potassium currents by the vesnarinone analog OPC-18790: comparison with quinidine and dofetilide

OPC-18790 is a vesnarinone analog currently in clinical trials for treatment of heart failure. In vitro studies have shown that, in addition to its positive inotropic actions, OPC-18790 prolongs cardiac action potentials. Therefore, in this study, the effects of OPC-18790 on cardiac potassium currents were compared with those we previously observed for the blockers quinidine and dofetilide in two test systems, i.e., L-cells stably transfected with mammalian cardiac potassium channel clones (Kv1.4, Kv1.5 and Kv2.1) and mouse AT-1 cells, in which the rapidly inactivating component of the cardiac delayed rectifier (I(Kr)) is the major repolarizing current. In L-cells, 10 to 100 microM OPC-18790 reduced Kv1.4, Kv1.5 and Kv2.1 currents by <30%, whereas quinidine was a more potent blocker (EC50 < 10 microM) and the I(Kr)-specific blocker dofetilide was without effect. In contrast, in AT-1 cells, OPC-18790 blocked I(Kr) with an EC50 (0.96 +/- 0.12 microM, n = 10) similar to that of quinidine (0.9 +/- 0.2 microM). For both drugs, block was voltage dependent, increasing at positive potentials. OPC-18790 and quinidine showed no frequency dependence, implying block of resting channels and/or very rapid block of open channels; this is in contrast to dofetilide, which displayed slow onset kinetics of block. Thus, we conclude that, 1) unlike quinidine, OPC-18790 does not significantly inhibit currents obtained by expression of the cardiac potassium channel clones Kv1.4, Kv1.5 and Kv2.1; 2) like quinidine and dofetilide, OPC-18790 blocks I(Kr) in AT-1 cells, but the kinetics of block onset more closely resemble those of quinidine than dofetilide; and 3) block of I(Kr) appears to be an important mechanism underlying the action potential-prolonging properties of OPC-18790.

A practical approach to torsade de pointes

The term torsade de pointes refers to polymorphic ventricular tachycardia that occurs in the setting of an abnormally long QT interval. While the most common cause is treatment with QT prolonging drugs, torsade de pointes also occurs in the congenital long QT syndromes and in the setting of acquired heart block or severe electrolyte disturbance, notably hypokalemia. Among QT prolonging drugs that cause torsade de pointes, both antiarrhythmics and "noncardioactive" drugs have been recognized. The electrocardiographic features of torsade de pointes include labile QT intervals, prominent U waves, and a "pause-dependent" onset of the arrhythmia. Treatment consists of recognition of the syndrome, correction of underlying electrolyte abnormalities, and withdrawal of any offending drugs. Magnesium, isoproterenol, or cardiac pacing provides specific antiarrhythmic therapy in torsade de pointes.

Multiple mechanisms in the long-QT syndrome. Current knowledge, gaps, and future directions. The SADS Foundation Task Force on LQTS

The congenital long-QT syndrome (LQTS) is characterized by prolonged QT intervals, QT interval lability, and polymorphic ventricular tachycardia. The manifestations of the disease vary, with a high incidence of sudden death in some affected families but not in others. Mutations causing LQTS have been identified in three genes, each encoding a cardiac ion channel. In families linked to chromosome 3, mutations in SCN5A, the gene encoding the human cardiac sodium channel, cause the disease, Mutations in the human ether-à-go-go-related gene (HERG), which encodes a delayed-rectifier potassium channel, cause the disease in families linked to chromosome 7. Among affected individuals in families linked to chromosome 11, mutations have been identified in KVLQT1, a newly cloned gene that appears to encode a potassium channel. The SCN5A mutations result in defective sodium channel inactivation, whereas HERG mutations result in decreased outward potassium current. Either mutation would decrease net outward current during repolarization and would thereby account for prolonged QT intervals on the surface ECG. Preliminary data suggest that the clinical presentation in LQTS may be determined in part by the gene affected and possibly even by the specific mutation. The identification of disease genes in LQTS not only represents a major milestone in understanding the mechanisms underlying this disease but also presents new opportunities for combined research at the molecular, cellular, and clinical levels to understand issues such as adrenergic regulation of cardiac electrophysiology and mechanisms of susceptibility to arrhythmias in LQTS and other settings.

Ionic mechanisms for prolongation of refractoriness and their proarrhythmic and antiarrhythmic correlates

Drugs that prolong cardiac refractoriness exert antiarrhythmic effects, probably by reducing dispersion of refractoriness and thereby reducing the likelihood of reentrant excitation. This electrophysiologic effect can be achieved in fast-response tissues by sodium channel block or by action potential prolongation; drugs with either attribute can exert antiarrhythmic effects. However, both types of drugs can also cause proarrhythmic effects. For sodium channel blockers, proarrhythmic actions can be attributed to conduction slowing and include increased frequency of episodes of ventricular tachycardia as well as slowing of atrial flutter with 1:1 atrioventricular conduction and increases in ventricular rate. In addition, sodium channel block has been implicated as the mechanism underlying increased mortality with sodium channel blockers in the Cardiac Arrhythmia Suppression Trial (CAST); some data suggest that intercurrent ischemia increases this risk. For drugs that prolong action potentials, torsades de pointes is the most common proarrhythmic syndrome, occurring most often with underlying bradyarrhythmias and hypokalemia. The mechanism(s) underlying normal refractoriness and its modulation by antiarrhythmic drugs, as well as the mechanism(s) underlying these proarrhythmic syndromes, are discussed.

Suprachoroidal effusion following argon laser trabeculoplasty

PURPOSE

This is first report of suprachoroidal effusion occurring subsequent to argon laser trabeculoplasty (ALT).

METHODS

Review of the records of the patients in question.

RESULTS

A 77-year-old woman with bilateral pseudophakia and primary open-angle glaucoma was treated with ALT when her visual fields deteriorated despite topical timolol therapy. Although ALT was initially performed without complication in one eye, treatment of the other eye led to a choroidal detachment. This was associated with temporary reduction in visual acuity, shallowing of the anterior chamber and hypotony.

CONCLUSION

Suprachoroidal effusion appears to be another complication of ALT. In the reported case, this application and its effects were temporary and resolved with conservative management.

Regulation of sodium current development in cultured atrial tumor myocytes (AT-1 cells)

AT-1 cells, derived from atrial tumors in transgenic mice, have many features similar to cardiac myocytes. However, their sodium current (INa) has not been evaluated on detail. In this study, two INa phenotypes were identified in AT-1 cells: one at 3 days in culture and the other at 14 days. INa was smaller at 3 days than at 14 days (12 +/- 2 vs. 37 +/- 5 pA/pF) and activated more slowly (time to peak INa at -30 mV: 9.8 +/- 0.4 vs. 1.4 +/- 0.1 ms). Inactivation at 14 days was faster and shifted 16 mV negative compared with that at 3 days. Acute protein kinase A or C stimulation in 3-day cells did not alter INa gating. However, the 14-day phenotype was observed in 3-day cells when the adenosine 3',5'-cyclic monophosphate analogue 8-(4-chlorophenylthio)-adenosine 3',5'-cyclic monophosphate, the phorbol ester phorbol 12-myristate 13-acetate, or okadaic acid was added to the culture medium from days 0 to 3. Conversely, adenosine 3',5'-cyclic monophosphothioate triethylamine, the protein kinase A inhibitor, prevented the normal development of the 14-day phenotype if the exposure was early and reverted the phenotype to that at 3 days if the exposure was later. Thus, in AT-1 cells, as in other mammalian cardiac myocytes, INa undergoes a maturation process that is dependent on intracellular phosphorylation processes. The data raise the possibility that an important consequence of altered intracellular signaling in disease is lability in INa amplitude or gating.

Epinephrine-induced changes in serum potassium and cardiac repolarization and effects of pretreatment with propranolol and diltiazem

Although increases in serum epinephrine are known to cause hypokalemia, the epinephrine dosages and concentrations at which this effect occurs, and the electrocardiographic consequences, have not been evaluated. Because epinephrine infusion is now being used to provoke arrhythmias in some patients, we have determined the physiologic effects of a range of dosages of epinephrine. The effects of pretreatment with propranolol and diltiazem on these indexes of epinephrine effect were also evaluated. Epinephrine dose ranging started at 10 ng/kg/min, with doubling of the dose every 10 minutes until a predetermined end point was reached. At the end of each dosage level, serum electrolytes, catecholamines, and an electrocardiogram were recorded. Whereas even the lowest dosage of epinephrine significantly increased heart rate, serum glucose levels increased and serum potassium decreased only when dosages of 160 to 320 ng/kg/min were administered. Plasma concentrations of epinephrine at these dosages were mean +/- SD 1,328 +/- 902 pg/ml, comparable to those observed in these subjects during maximal exercise (1,003 +/- 527 pg/ml). The major electrocardiographic effect of epinephrine infusion was a dose-related increase in QTc, but pretreatment with propranolol blunted this effect and tended to shorten QTc. At an epinephrine dose of 40 ng/kg/min, QTc prolongation persisted and was inhibited by diltiazem. These data suggest that the major electrocardiographic effect of epinephrine infusion is mediated by increased calcium current. At dosages > 80 ng/kg/min, plasma epinephrine concentrations are comparable to those observed with severe stress, and hypokalemia is common. The use of epinephrine as an electrophysiologic provoker at dosages > 80 ng/kg/min results in both a direct effect, as well as an indirect effect due to hypokalemia.

Loss of quinidine gluconate injection in a polyvinyl chloride infusion system

The effect of a polyvinyl chloride (PVC) i.v. administration system on the availability of quinidine gluconate was studied. Quinidine gluconate diluted in 5% dextrose injection was administered intravenously to five healthy volunteers via conventional PVC infusion sets, and the subjects received oral quinidine sulfate two days later. The mean +/- S.D. oral bioavailability of quinidine was, unexpectedly, greater than 100% (147 +/- 44%). To test the possibility that this occurred because of reduced delivery of i.v. quinidine, the percentage of drug delivered via two systems was evaluated in simulation studies, one involving a conventional PVC administration set and the other a glass syringe attached to shorter PVC tubing and a winged i.v. catheter. Spectrophotometric analysis revealed a 5-7% reduction in absorbance associated with loss of quinidine in the PVC infusion bag and a further 34-38% reduction in absorbance attributable to quinidine loss in the PVC tubing. However, with the winged i.v. catheter system the loss was reduced to less than 3%. More than 40% of a dose of quinidine gluconate was lost when the drug was administered with a conventional PVC i.v. administration set. Drug loss was reduced by using a winged i.v. catheter and shorter tubing.

The cardiac ion channels: relevance to management of arrhythmias

The electrical activity of cardiac tissue is determined by the highly regulated flow of ions across the cell membrane during the cardiac action potential. Ion channels are pore-forming proteins through which these electric currents flow. In this review, the ion currents that underlie the action potential are first described. Then, the way in which expression of individual ion-channel genes results in such ion currents is discussed. Finally, the concept that arrhythmias may be due to abnormalities of structure, function, or number of ion channels, or the way in which they respond to abnormalities in their environment (such as acute ischemia), is reviewed. Further understanding of the molecular mechanisms underlying normal and abnormal cardiac electrophysiologic behavior should allow the development of safer and more effective antiarrhythmic interventions.

Is there a need for new antiarrhythmic drugs?

Currently available antiarrhythmic drugs were developed at a time when the basic mechanisms underlying most arrhythmias were conjectural at best. Indeed, the molecular targets upon which drugs act to prevent (or to exacerbate) arrhythmias are only now being defined. Thus, recent advances in the treatment of patients with arrhythmias have emphasized non-pharmacologic approaches, which use new information on the pathophysiology of specific arrhythmias to deliver targeted therapies. For some arrhythmias, such as atrial fibrillation, it seems likely that drug therapy will remain an important part of treatment. With increasing cellular and molecular understanding of the determinants of normal and abnormal cardiac electrogenesis, it should be possible to develop effective and safer drugs for the treatment of cardiac arrhythmias.