hERG potassium channels and cardiac arrhythmia

Identification of IKr and Its Trafficking Disruption Induced by Probucol in Cultured Neonatal Rat Cardiomyocytes

The human ether-a-go-go-related gene (hERG) encodes a channel that conducts the rapidly activating delayed rectifier K(+) current (I(Kr)), which is important for cardiac repolarization. Mutations in hERG reduce I(Kr) and cause congenital long QT syndrome (LQTS). More frequently, common medications can reduce I(Kr) and cause LQTS as a side effect. Protein trafficking abnormalities are responsible for most hERG mutation-related LQTS and are recently recognized as a mechanism for drug-induced LQTS. Whereas hERG trafficking has been studied in recombinant expression systems, there has been no reported study on cardiac I(Kr) trafficking at the protein level. In the present study, we identified that I(Kr) is present in cultured neonatal rat ventricular myocytes and can be robustly recorded using Cs(+) as the charge carrier. We further discovered that 4,4'-(isopropylidenedithio)-bis-(2,6-di-t-butylphenol) (probucol), a cholesterol-lowering drug that induces LQTS, disrupted I(Kr) trafficking and prolonged the cardiac action potential duration. Probucol did not directly block I(Kr). Probucol also disrupted hERG trafficking and did not block hERG channels expressed in human embryonic kidney 293 cells. We conclude that probucol induces LQTS by disrupting ether-a-go-go-related gene trafficking, and that primary culture of neonatal rat cardiomyocytes represents a useful system for studying native I(Kr) trafficking.

Vernakalant (RSD1235): a novel, atrial-selective antifibrillatory agent

This review summarizes the mechanistic properties and the recent experience in the development of a new antiarrhythmic agent, RSD1235 (recently named vernakalant), for the acute conversion of atrial fibrillation to sinus rhythm. Atrial fibrillation is the most common sustained cardiac arrhythmia that is observed in clinical practice and is associated with increased morbidity and mortality, resulting from stroke and exacerbation of heart failure. At present, there is a lack of pharmacologic agents that are able to safely and effectively convert the arrhythmia back to sinus rhythm. Vernakalant has the electrophysiologic properties of a multiple ion channel blocker, developed using a novel approach to target potassium channels that are selectively present in human atria rather than ventricles, and using a rate-dependent blocking strategy for its additional sodium channel block. This paper reviews the mechanism of action of this drug, its performance in preclinical models of efficacy and human disease, and its actions on patients in the completed and published preregistration clinical trials for vernakalant. Overall, vernakalant converted 51.5% of patients who had < 7 days duration of atrial fibrillation and it did this without significantly more cardiovascular adverse events than placebo. Therefore, it must be considered as an important new agent for the treatment of this growing health problem.

Mechanism of block of the hERG K+ channel by the scorpion toxin CnErg1

The scorpion toxin CnErg1 binds to human ether-a-go-go related gene (hERG) K(+) channels with a 1:1 stoichiometry and high affinity. However, in contrast to other scorpion toxin-ion channel interactions, the inhibition of macroscopic hERG currents by high concentrations of CnErg1 is incomplete. In this study, we have probed the molecular basis for this incomplete inhibition. High concentrations of CnErg1 had only modest effects on hERG gating that could not account for the incomplete block. Furthermore, the residual current in the presence of 1 microM CnErg1 had normal single channel conductance. Analysis of the kinetics of CnErg1 interaction with hERG indicated that CnErg1 binding is not diffusion-limited. A bimolecular binding scheme that incorporates an initial encounter complex and permits normal ion conduction was able to completely reproduce both the kinetics and steady-state level of CnErg1-hERG binding. This scheme provides a simple kinetic explanation for incomplete block; that is, relatively fast backward compared to forward rate constants for the interconversion of the toxin-channel encounter complex and the blocked toxin-channel complex. We have also examined the temperature-dependence of CnErg1 binding to hERG. The dissociation constant, K(d), for CnErg1 increases from 7.3 nM at 22 degrees C to 64 nM at 37 degrees C (i.e., the affinity decreases as temperature increases) and the proportion of binding events that lead to channel blockade decreases from 70% to 40% over the same temperature range. These temperature-dependent effects on CnErg1 binding correlate with a temperature-dependent decrease in the stability of the putative CnErg1 binding site, the amphipathic alpha-helix in the outer pore domain of hERG, assayed using circular dichroism spectropolarimetry. Collectively, our data provides a plausible kinetic explanation for incomplete blockade of hERG by CnErg1 that is consistent with the proposed highly dynamic conformation of the outer pore domain of hERG.

KCNQ potassium channel mutations cause cardiac arrhythmias in Drosophila that mimic the effects of aging

Population profiles of industrialized countries show dramatic increases in cardiovascular disease with age, but the molecular and genetic basis of disease progression has been difficult to study because of the lack of suitable model systems. Our studies of Drosophila show a markedly elevated incidence of cardiac dysfunction and arrhythmias in aging fruit fly hearts and a concomitant decrease in the expression of the Drosophila homolog of human KCNQ1-encoded K(+) channel alpha subunits. In humans, this channel is involved in myocardial repolarization, and alterations in the function of this channel are associated with an increased risk for Torsades des Pointes arrhythmias and sudden death. Hearts from young KCNQ1 mutant fruit flies exhibit prolonged contractions and fibrillations reminiscent of Torsades des Pointes arrhythmias, and they exhibit severely increased susceptibility to pacing-induced cardiac dysfunction at young ages, characteristics that are observed only at advanced ages in WT flies. The fibrillations observed in mutant flies correlate with delayed relaxation of the myocardium, as revealed by increases in the duration of phasic contractions, extracellular field potentials, and in the baseline diastolic tension. These results suggest that K(+) currents, mediated by a KCNQ channel, contribute to the repolarization reserve of fly hearts, ensuring normal excitation-contraction coupling and rhythmical contraction. That arrhythmias in both WT and KCNQ1 mutants become worse as flies age suggests that additional factors are also involved.

Advantages of voltage-gated ion channels as drug targets

Many human diseases result from over- or underactivity in one or more critical physiologic systems. One of the foremost challenges in modern drug discovery is the identification and selection of cellular proteins that can be specifically targeted with therapeutic agents in order to normalize aberrant processes/systems. Suitable drug targets must be validated in the human disease state and ideally, the targeted protein will fulfill similar physiologic and pathologic functions in humans and at least one animal species so that in vivo efficacy and toxicology assays with some predictive clinical relevance may be developed. Nowadays, drug targets must also be amenable to high-throughput screening so that novel molecules, which are capable of modifying cellular protein function, can be identified in large libraries of compounds. Voltage-gated ion channels satisfy many of these requirements and, as a class, are viewed as promising drug targets. Nevertheless, despite their relevance to human disease, voltage-gated ion channels remain considerably underexploited. Therein lie some of the opportunities and advantages associated with voltage-gated ion channels as drug targets.

Toxins interacting with ether-à-go-go-related gene voltage-dependent potassium channels

The critical role that ether-à-go-go-related gene (erg) K(+) channels play in mating in Caenorhabditis elegans, neuronal seizures in Drosophila and cardiac action potential repolarization in humans has been well documented. Three erg genes (erg1, erg2 and erg3) have been identified and characterized. A structurally diverse number of compounds block these channels, but do not display specificity among the different channel isoforms. In this review we describe the blocking properties of several peptides, purified from scorpion, sea anemone and spider venoms, which are selective for certain members of the ERG family of channels. These peptides do not behave as classical pore blockers and appear to modify the gating properties of the channel. Genomic studies predict the existence of many other novel peptides with the potential of being more selective for ERG channels than those discussed here.

The pacemaker current: from basics to the clinics

Activation of the pacemaker ("funny," I(f)) current during diastole is the main process underlying generation of the diastolic depolarization and spontaneous activity of cardiac pacemaker cells. I(f) modulation by autonomic transmitters is responsible for the chronotropic regulation of heart rate. Given its role in pacemaking, I(f) has been a major target of investigation aimed to exploit its rate-controlling function in a clinical perspective. In this short review, we describe some of the most recent clinically relevant applications of the concept of I(f)-based pacemaking.

Preclinical cardio-safety assessment of torsadogenic risk and alternative methods to animal experimentation: The inseparable twins

The last decade has been marked by the withdrawal from the market of several medicines whose use in patients has been associated with the development of torsade de pointes (TdP), a potentially life-threatening polymorphic tachycardia. In a few cases, TdP can degenerate into ventricular fibrillation and lead to sudden death, thus constituting a real problem of public health. The recently finalized ICH S7B guideline defines the prolongation of the QT interval on the electrocardiogram as the best biomarker for predicting the torsadogenic risk of a given compound. However, a growing body of evidence suggests that drugs' torsadogenic potential may not necessarily be proportional to their ability to prolong the QT interval. It is a dynamic combination of multiple predisposing factors and components rather than a single particular event that can trigger this particular tachycardia. Following recommendations of the guideline, pharmaceutical companies have intensively implemented methodologies to assess the possible risk of QT prolongation and TdP in humans. The main problem in cardiac safety pharmacology is how best to combine the capabilities of different methodologies with their strengths and limitations in order to detect the potential of one molecular entity to induce a lethal arrhythmia of very low clinical incidence. This publication will review the current methodologies, focusing on the alternative methods to animal experimentation, including an overview of cardiac modeling.

Interaction Simulation of hERG K+ Channel with Its Specific BeKm-1 Peptide: Insights into the Selectivity of Molecular Recognition

Potassium channels show a huge variability in the affinity when recognizing enormous bioactive peptides, and the elucidation of their recognition mechanism remains a great challenge due to an undetermined peptide-channel complex structure. Here, we employed combined computation methods to study the specific binding of BeKm-1 peptide to the hERG potassium channel, which is an essential determinant of the long-QT syndrome. By the use of a segment-assembly homology modeling method, the closed-state hERG structure containing unusual longer S5P linker was successfully constructed. It has a "petunia" shape, while four "petals" of symmetrically distributed S5P segments always decentralize. Starting from the hERG and BeKm-1 structures, a considerably reasonable BeKm-1-hERG complex structure was then screened out and identified by protein-protein docking, molecular dynamics (MD) simulations, and calculation of relative binding free energies. The validity of this predicted complex was further assessed by computational alanine-scanning, with the results correlating reasonably well with experimental data. In the novel complex structure, four considerably flexible S5P linkers are far from the BeKm-1 peptide. The BeKm-1 mainly uses its helical region to associate the channel outer vestibule, except for the S5P linker region; however, structural analysis further implies this neutral pore region with wiggling S5P linker is highly beneficial to the binding of BeKm-1 with lower positive charges. The most critical Lys18 of BeKm-1 plugs its side chain into the channel selectivity filter, while the secondarily important Arg20 forms three hydrogen bonds with spatially neighboring residues in the hERG channel. Different from the classical peptide-K+ channel interaction mainly induced by electrostatic interaction, a synergetic effect of the electrostatic and van der Waals interactions was found to mediate the molecular recognition between BeKm-1 and the hERG channel. And this specific binding process is revealed to be a dynamic change of reduction of binding free energy and conformational rearrangement mainly in the interface of both BeKm-1 and the hERG channel. All these structural and energy features yield deep insights on the high selective binding mechanism of hERG-specific peptides, present a diversity of peptide-K+ channel interactions, and also provide important clues to further study structure-function relationships of the hERG channel.

Comparison of K+ currents in cardiac Purkinje cells isolated from rabbit and dog

The repolarization reserve determines the ability of drugs to prolong the cardiac action potential duration. Differences in K(+) currents between rabbit and dog cardiac Purkinje cells were studied by recording the transient outward K(+) current (I(to)) as well as the delayed rectifier K(+) currents (I(Ks) and I(Kr)) during repolarization. Purkinje fibers were dissected from dog and rabbit hearts and exposed to enzymatic digestion until isolated cells were obtained. Whole cell voltage clamp methods were used to measure K(+) currents in both cell types. Action potential (AP) recordings from Purkinje cells displayed a rapid phase 1 repolarization due to a prominent I(to) with densities of 13.3+/-2.3 and 9.6+/-0.6 pA/pF at +40 mV in dog and rabbit respectively. I(Ks) tail currents were significantly larger in dog Purkinje cells. I(Kr) tail current densities were comparable in Purkinje cell from both species. Rabbit ventricular and Purkinje cell AP waveforms were used for action potential clamp experiments in TSA201 cells expressing human ether a go-go related gene (HERG). HERG currents elicited by the ventricular waveform reached its maximum amplitude during phase 3 repolarization. In contrast, Purkinje cell AP waveform elicited markedly smaller HERG currents even though the action potential duration was longer. The observations suggest that the fast phase 1 and negative plateau of the Purkinje cell AP limits the contribution of I(Kr) to repolarization. These results provide evidence that rabbit Purkinje cells have a smaller repolarization reserve and provide a biophysical explanation for a previously observed higher sensitivity to QT prolonging drugs in rabbit than dog Purkinje fibers.

Activation of hEAG1 potassium channels by arachidonic acid

The depolarisation activated human ether à go-go (hEAG) potassium channels are primarily expressed in neuronal tissue but their appearance in various tumour entities is also indicative of an oncogenic role. Because upregulation of hEAG channels may yield to an enhanced cell proliferation, interventions increasing hEAG1 currents may serve similar purposes. We therefore investigated the effects of polyunsaturated fatty acids on hEAG1 channels. Arachidonic acid (AA) lowered their activation threshold, accelerated the activation kinetics and increased the open probability with a half-maximal concentration of about 4 microM. This effect correlated with the number of double bonds (db) in the fatty acids, increasing from oleic acid (1 db), linolenic acid (3 db), AA (4 db) to eicosapentaenoic acid (5 db). Unlike other voltage-gated K(+) channels, hEAG1 channels are not blocked by arachidonic acid. Therefore, in particular at typical resting potentials of tumour cells (-30 mV), AA potently activated hEAG1 channels in a reversible manner. Proliferation and metabolic activity of hEAG1-expressing human melanoma cells increased when cells were exposed to AA concentrations of 5 microM and this effect was suppressed in the presence of the hEAG1 blocker LY97241 suggesting that the proliferative effect of AA is in part mediated by activation of hEAG channels.

Cardiac glycosides as novel inhibitors of human ether-a-go-go-related gene channel trafficking

Direct block of the cardiac potassium channel human ether-a-go-go-related gene (hERG) by a large, structurally diverse group of therapeutic compounds causes drug-induced QT prolongation and torsades de pointes arrhythmias. In addition, several therapeutic compounds have been identified more recently that prolong the QT interval by inhibition of hERG trafficking to the cell surface. We used a surface expression assay to identify novel compounds that interfere with hERG trafficking and found that cardiac glycosides are potent inhibitors of hERG expression at the cell surface. Further investigation of digitoxin, ouabain, and digoxin revealed that all three cardiac glycosides reduced expression of the fully glycosylated cell surface form of hERG on Western blots, indicating that channel exit from the endoplasmic reticulum is blocked. Likewise, hERG currents were reduced with nanomolar affinity on long-term exposure. hERG trafficking inhibition was initiated by cardiac glycosides through direct block of Na(+)/K(+) pumps and not via off-target interactions with hERG or another closely associated protein in its processing or export pathway. In isolated guinea pig myocytes, long-term exposure to 30 nM of the clinically used drugs digoxin or digitoxin reduced hERG/rapidly activating delayed rectifier K(+) current (I(Kr)) currents by approximately 50%, whereas three other cardiac membrane currents--inward rectifier current, slowly activating delayed rectifier K(+) current, and calcium current--were not affected. Importantly, 100 nM digitoxin prolonged action potential duration on long-term exposure consistent with a reduction in hERG/I(Kr) channel number. Thus, cardiac glycosides are able to delay cardiac repolarization at nanomolar concentrations via hERG trafficking inhibition, and this may contribute to the complex electrocardiographic changes seen with compounds such as digitoxin.

hERG1 channels in human esophagus: evidence for their aberrant expression in the malignant progression of Barrett's esophagus

Ion channels regulate a broad range of cellular activities. Alteration in ion channel function has been reported in different human pathologies, such as cardiac, neuromuscular, autoimmune diseases, and cancer. We investigated the expression of hERG1 K+ channels in the human upper gastrointestinal tract, focusing our attention on the lower esophagus. In particular, we analyzed by both Reverse transcription and polymerase chain reaction (RT-PCR) and immunohistochemistry (IHC) endoscopic samples obtained from normal subjects, from patients suffering from gastroesophageal reflux, associated or not with esophagitis, and from patients affected by Barrett's esophagus (BE), that is, intestinal metaplasia. None of the normal samples, nor those from patients with gastro-esophageal reflux symptoms and reflux esophagitis expressed the hERG1 protein. On the other hand, 69% of patients with BE expressed hERG1. Since BE is a preneoplastic lesion, dysplasias (Ds) and adenocarcinomas (ADKs) arising on a previously diagnosed BE were also analyzed, and all the samples showed a high expression of the hERG1 protein. The surveillance of patients with BE showed that 89% of those who later developed ADKs displayed hERG1 expression. Data here reported, support the hypothesis that hERG1 expression marks an early step of the progression of normality to cancer in the human esophagus through a metaplastic and dysplastic stage.

Combined hERG channel inhibition and disruption of trafficking in drug-induced long QT syndrome by fluoxetine: a case-study in cardiac safety pharmacology

Drug-induced prolongation of the rate-corrected QT interval (QTCI) on the electrocardiogram occurs as an unwanted effect of diverse clinical and investigational drugs and carries a risk of potentially fatal cardiac arrhythmias. hERG (human ether-à-go-go-related gene) is the gene encoding the alpha-subunit of channels mediating the rapid delayed rectifier K+ current, which plays a vital role in repolarising the ventricles of the heart. Most QTCI prolonging drugs can inhibit the function of recombinant hERG K+ channels, consequently in vitro hERG assays are used widely as front-line screens in cardiac safety-testing of novel chemical entities. In this issue, Rajamani and colleagues report a case of QTCI prolongation with the antidepressant fluoxetine and correlate this with a dual effect of the drug and of its major metabolite norfluoxetine on hERG channels. Both compounds were found to produce an acute inhibition of the hERG channel by pharmacological blockade, but in addition they also were able to disrupt the normal trafficking of hERG protein to the cell membrane. Mutations to a key component of the drug binding site in the S6 region of the channel greatly attenuated channel block, but did not impair disruption of trafficking; this suggests that channel block and drug effects on trafficking were mediated by different mechanisms. These findings add to growing evidence for disruption of hERG channel trafficking as a mechanism for drug-induced long QT syndrome and raise questions as to possible limitations of acute screening methods in the assessment of QTcI prolonging liability of drugs in development.

Disopyramide is an effective inhibitor of mutant HERG K+ channels involved in variant 1 short QT syndrome

The recently identified idiopathic short QT syndrome (SQTS) is associated with an increased risk of arrhythmia and sudden death. The use of implantable cardioverter defibrillators helps to protect SQTS patients from ventricular fibrillation; however, pharmacological treatments to normalise the QT interval are limited: thus far only quinidine has been found to be effective in a subset of patients, with the SQT1 variant. SQT1 is associated with an amino acid substitution (N588K) in the KCNH2-encoded HERG K(+) channel that reduces HERG current (I(HERG)) inactivation and sensitivity to drug block. We demonstrate here that the N588K-HERG mutation only slightly attenuates I(HERG) blockade by the Class Ia antiarrhythmic drug disopyramide (1.5-fold elevation of IC(50)), compared to quinidine (3.5-fold elevation of IC(50)) and the Class III antiarrhythmic drug E-4031 (11.5-fold elevation of IC(50)). Thus, of the drugs studied to date, disopyramide is the one least affected by the SQT1 HERG mutation. Disopyramide is associated with QT prolongation in normal use and our findings provide a rational basis for its evaluation as a treatment for SQT1.

Different relevance of inactivation and F468 residue in the mechanisms of hEag1 channel blockage by astemizole, imipramine and dofetilide

The relevance of a point mutation at the C-terminal end of the S6 helix (F468) and the introduction of C-type inactivation in the blockage of hEag1 channels by astemizole, imipramine and dofetilide was tested. C-type inactivation decreased block by astemizole and dofetilide but not imipramine, suggesting different binding sites in the channel. F468C mutation increased IC(50) for astemizole and imipramine but in contrast to HERG channels, only slightly for dofetilide. Together with measurements on recovery of blocking, our observations indicate that the mechanism of hEag1 blockage by each of these drugs is different, and suggest relevant structural differences between hEag1 and HERG channels.

Mallotoxin Is a Novel HumanEther-a-go-go-Related Gene (hERG) Potassium Channel Activator

Human ether-a-go-go-related gene (hERG) encodes a rapidly activating delayed rectifier potassium channel that plays important roles in cardiac action potential repolarization. Although many drugs and compounds block hERG channels, activators of the channel have only recently been described. Three structurally diverse synthetic compounds have been reported to activate hERG channels by altering deactivation or inactivation or by unidentified mechanisms. Here, we describe a novel, naturally occurring hERG channel activator, mallotoxin (MTX). The effects of MTX on hERG channels were investigated using the patch-clamp technique. MTX increased both step and tail hERG currents with EC(50) values of 0.34 and 0.52 microM, respectively. MTX leftward shifted the voltage dependence of hERG channel activation to less depolarized voltages ( approximately 24 mV at 2.5 microM). In addition, MTX increased hERG deactivation time constants. MTX did not change the half-maximal inactivation voltage of the hERG channel, but it reduced the slope of the voltage-dependent inactivation curve. All of these factors contribute to the enhanced activity of hERG channels. During a voltage-clamp protocol using prerecorded cardiac action potentials, 2.5 microM MTX increased the total potassium ions passed through hERG channels by approximately 5-fold. In conclusion, MTX activates hERG channels through distinct mechanisms and with significantly higher potency than previously reported hERG channel activators.

Predictive value of in vitro safety studies

The predictive value of in vitro safety studies is discussed for three important areas of pharmaceutical safety evaluations. In genetic toxicology, currently assays are sensitive for the prediction of cancer, but their overall predictive value is strongly diminished because of their low specificity. In the area of safety pharmacology blockage of hERG channel in vitro has recently been introduced to predict cardiac repolarization delay (QT interval prolongation) in patients. There is a plethora of in vitro methods to predict and characterize liver toxicity. However, little data is available that demonstrate a reliable prediction for hepatotoxicity in vivo over a wide range of chemical structures. In all three areas, further improvements are needed. 'Omics' technologies and new cell lines derived from stem cells are expected to strongly contribute to establish new and more predictive in vitro assays.