The long QT syndromes: genetic basis and clinical implications

Thermodynamic and kinetic properties of amino-terminal and S4-S5 loop HERG channel mutants under steady-state conditions

Gating kinetics and underlying thermodynamic properties of human ether-a-go-go-related gene (HERG) K(+) channels expressed in Xenopus oocytes were studied using protocols able to yield true steady-state kinetic parameters. Channel mutants lacking the initial 16 residues of the amino terminus before the conserved eag/PAS region showed significant positive shifts in activation voltage dependence associated with a reduction of z(g) values and a less negative DeltaG(o), indicating a deletion-induced displacement of the equilibrium toward the closed state. Conversely, a negative shift and an increased DeltaG(o), indicative of closed-state destabilization, were observed in channels lacking the amino-terminal proximal domain. Furthermore, accelerated activation and deactivation kinetics were observed in these constructs when differences in driving force were considered, suggesting that the presence of distal and proximal amino-terminal segments contributes in wild-type channels to specific chemical interactions that raise the energy barrier for activation. Steady-state characteristics of some single point mutants in the intracellular loop linking S4 and S5 helices revealed a striking parallelism between the effects of these mutations and those of the amino-terminal modifications. Our data indicate that in addition to the recognized influence of the initial amino-terminus region on HERG deactivation, this cytoplasmic region also affects activation behavior. The data also suggest that not only a slow movement of the voltage sensor itself but also delaying its functional coupling to the activation gate by some cytoplasmic structures possibly acting on the S4-S5 loop may contribute to the atypically slow gating of HERG.

Modification of K+ channel-drug interactions by ancillary subunits

Reconciling ion channel alpha-subunit expression with native ionic currents and their pharmacological sensitivity in target organs has proved difficult. In native tissue, many K(+) channel alpha-subunits co-assemble with ancillary subunits, which can profoundly affect physiological parameters including gating kinetics and pharmacological interactions. In this review, we examine the link between voltage-gated potassium ion channel pharmacology and the biophysics of ancillary subunits. We propose that ancillary subunits can modify the interaction between pore blockers and ion channels by three distinct mechanisms: changes in (1) binding site accessibility; (2) orientation of pore-lining residues; (3) the ability of the channel to undergo post-binding conformational changes. Each of these subunit-induced changes has implications for gating, drug affinity and use dependence of their respective channel complexes. A single subunit may modulate its associated alpha-subunit by more than one of these mechanisms. Voltage-gated potassium channels are the site of action of many therapeutic drugs. In addition, potassium channels interact with drugs whose primary target is another channel, e.g. the calcium channel blocker nifedipine, the sodium channel blocker quinidine, etc. Even when K(+) channel block is the intended mode of action, block of related channels in non-target organs, e.g. the heart, can result in major and potentially lethal side-effects. Understanding factors that determine specificity, use dependence and other properties of K(+) channel drug binding are therefore of vital clinical importance. Ancillary subunits play a key role in determining these properties in native tissue, and so understanding channel-subunit interactions is vital to understanding clinical pharmacology.

Role of the S6 C-terminus in KCNQ1 channel gating

Co-assembly of KCNQ1 alpha-subunits with KCNE1 beta-subunits results in the channel complex underlying the cardiac IKs current in vivo. Like other voltage-gated K+ channels, KCNQ1 has a tetrameric configuration. The S6 segment of each subunit lines the ion channel pore with the lower part forming the activation gate. To determine residues involved in protein-protein interactions in the C-terminal part of S6 (S6T), alanine and tryptophan perturbation scans were performed from residue 348-362 in the KCNQ1 channel. Several residues were identified to be relevant in channel gating, as substitutions affected the activation and/or deactivation process. Some mutations (F351A and V355W) drastically altered the gating characteristics of the resultant KCNQ1 channel, to the point of mimicking the IKs current. Furthermore, mutagenesis of residue L353 to an alanine or a charged residue impaired normal channel closure upon hyperpolarization, generating a constitutively open phenotype. This indicates that the L353 residue is essential for stabilizing the closed conformation of the channel gate. These findings together with the identification of several LQT1 mutations in the S6 C-terminus of KCNQ1 underscore the relevance of this region in KCNQ1 and IKs channel gating.

Increasing gap junction coupling reduces transmural dispersion of repolarization and prevents torsade de pointes in rabbit LQT3 model

INTRODUCTION

Increased transmural dispersion of repolarization (TDR) contributes importantly to the development of torsades de pointes (TdP) in long QT syndrome (LQTS). Intercellular electrical coupling via gap junctions plays an important role in maintaining TDR in both normal and diseased hearts. This study examined the effects of antiarrhythmic peptide AAP10, a gap junction enhancer, on TDR and induction of TdP in a rabbit LQT3 model.

METHODS AND RESULTS

An arterially perfused rabbit left ventricular preparation and sea anemone toxin II (ATX-II, 20 nM) were used to establish a LQT3 model. Transmural ECG as well as action potentials from both endocardium and epicardium were simultaneously recorded. Changes in nonphosphorylated connexin43 (Cx43) were measured by immunoblotting. Compared with the control group, the QT interval, TDR, early afterdepolariztion (EAD), R-on-T extrasystole, and TdP increased sharply with augmented nonphosphorylated Cx43 in the LQT3 group (P < 0.001 for both). Interestingly, compared with the LQT3 group, 500 nM AAP10 reduced QT interval, TDR (P < 0.001 for both), and prevented EAD, R-on-T extrasystole, and TdP (P = 0.003, P = 0.001, P = 0.02) with a parallel decrease in nonphosphorylated Cx43 in the presence of ATX-II (P < 0.001).

CONCLUSION

Gap junction enhancer AAP10 is capable of abbreviating the QT interval, reducing TDR, and suppressing TdP in a rabbit LQT3 model probably via its effect by preventing dephosphorylation of Cx43. These data suggest that increasing intercellular coupling may reduce TDR and, therefore, prevent TdP in LQTS.

Hereditary long QT syndrome in pregnancy: antenatal and intrapartum management options

Long QT syndrome is a rare but severe cardiac arrhythmia. We report the antenatal and intrapartum management of a primigravida carrying the hereditary form of the disease and specifically the Romano-Ward syndrome. A multidisciplinary approach and close obstetric surveillance are mandatory for a good maternal and perinatal outcome. Follow-up of the neonate is equally important.

Incidence and risk factors of prolonged QTc interval in type 1 diabetes: the EURODIAB Prospective Complications Study

OBJECTIVE

Corrected QT (QTc) prolongation is predictive of cardiovascular mortality in both the general and diabetic populations. As part of the EURODIAB Prospective Complication Study, we have assessed the 7-year incidence and risk factors of prolonged QTc in people with type 1 diabetes.

RESEARCH DESIGN AND METHODS

A total of 1,415 type 1 diabetic subjects, who had normal QTc at baseline, were reanalyzed after the 7-year follow-up period. QTc >0.44 s was considered abnormally prolonged.

RESULTS

Cumulative incidence of prolonged QTc was 18.7%, which is twofold higher in women than in men (24.5 vs. 13.9%, P < 0.0001). At the baseline examination, incident cases were older and less physically active than nonincident cases, had higher mean values of systolic blood pressure and HDL cholesterol, and had higher frequencies of hypertension, coronary heart disease, and distal symmetrical polyneuropathy. In multivariate logistic regression analyses, female sex and higher values of A1C and systolic blood pressure were associated with the risk of prolonged QTc, whereas physical activity and BMI within the range of 21.5-23.2 kg/m2 were protective factors. In women, association with modifiable factors, particularly BMI, was stronger than in men.

CONCLUSIONS

In type 1 diabetic subjects from the EURODIAB cohort, female sex, A1C, and systolic blood pressure are predictive of prolonged QTc, whereas physical activity and BMI within the range of 21.5-23.2 kg/m2 play a protective role. These findings are clinically relevant, as they may help to identify subjects at higher risk for prolonged QTc, as well as provide potential targets for risk-lowering strategies.

A single hERG mutation underlying a spectrum of acquired and congenital long QT syndrome phenotypes

The long QT syndrome (LQTS) is a multi-factorial disorder that predisposes to life-threatening arrhythmias. Both hereditary and acquired subforms have been identified. Here, we present clinical and biophysical evidence that the hERG mutation c.1039 C>T (p.Pro347Ser or P347S) is responsible for both the acquired and the congenital phenotype. In one case the genotype remained silent for years until the administration of several QT-prolonging drugs resulted into a full-blown phenotype, that was reversible upon cessation of these compounds. On the other hand the mutation was responsible for a symptomatic congenital LQTS in a Dutch family, displaying a substantial heterogeneity of the clinical symptoms. Biophysical characterization of the p.Pro347Ser potassium channels using whole-cell patch clamp experiments revealed a novel pathogenic mechanism of reciprocal changes in the inactivation kinetics combined with a dominant-negative reduction of the functional expression in the heterozygous situation, yielding a modest genetic predisposition for LQTS. Our data show that in the context of the multi-factorial aetiology underlying LQTS a modest reduction of the repolarizing power can give rise to a spectrum of phenotypes originating from one mutation. This observation increases the complexity of genotype-phenotype correlations in more lenient manifestations of the disease and underscores the difficulty of predicting the expressivity of the LQTS especially for mutations with a more subtle impact such as p.Pro347Ser.

Kcnq1 contributes to an adrenergic-sensitive steady-state K+ current in mouse heart

It has been suggested that Kcne1 subunits are required for adrenergic regulation of Kcnq1 potassium channels. However, in adult mouse hearts, which do not express Kcne1, loss of Kcnq1 causes a Long QT phenotype during adrenergic challenge, raising the possibility that native Kcnq1 currents exist and are adrenergically regulated even in absence of Kcne1. Here, we used immunoblotting and immunohistochemical staining to show that Kcnq1 protein is present in adult mouse hearts. Voltage-clamp experiments demonstrated that Kcnq1 contributes to a steady-state outward current (I(SS)) in wild-type (Kcnq1(+/+)) ventricular myocytes during isoproterenol stimulation, resulting in a significant 7.1% increase in I(SS) density (0.43+/-0.16 pA/pF, p <0.05, n =15), an effect that was absent in Kcnq1-deficient (Kcnq1(-/-)) myocytes (-0.14+/-0.13 pA/pF, n =17). These results demonstrate for the first time that Kcnq1 protein is expressed in adult mouse hearts where it contributes to a beta-adrenergic-induced component of I(SS) that does not require co-assembly with Kcne1.

Implications of genetic testing for sudden cardiac death syndrome

The completion of the Human Genome Project in 2003 is shifting the focus of modern health care from disease management based on clinical signs to genomic-based treatment and prevention. Nurses at all levels of practice are going to increasingly come under pressure to deliver evidence-based, competent care to families undergoing genetic testing for hereditary conditions (Skirton and Barnes, 2005). A new chapter added to the National Service Framework for Coronary Heart Disease in 2005 raised awareness of the genetic basis of up to 400 sudden cardiac deaths that occur every year in the UK (Department of Health, 2005). This article addresses some of the clinical and ethical implications for nurses caring for families who may be at risk of an inherited sudden cardiac death syndrome. Nursing practice implications are discussed, concluding that more research is needed to explore how family members cope with genetic information which will shape the provision of future genetic healthcare.

Body surface ECG signal shape dispersion

The spatial distribution of the shape of the electrocardiography (ECG) waves obtained by body surface potential mapping (BSPM) is studied, using a 64-channel high-resolution ECG system. The index associated to each lead is the shape difference between its ECG wave and a reference computed taking into account all the leads on the same column. The reference is either a selected real wave or a synthetic signal computed by integral shape averaging (ISA). Better results are obtained with the ISA signal using the distribution function method (DFM) for computing the shape difference. The spatial dispersion of ECG waves is showed to allow the separation of patients after myocardial infarction (MI) from healthy subjects. In addition, the reference signal position for each column is computed. The path linking these positions appears as an invariant, i.e., it is independent of the subject and the ECG wave.

Familial Mahaim syndrome

We describe the occurrence of Mahaim syndrome in a mother and her son. The occurrence of such a rare disorder in two members of a family is noteworthy, has not been reported before, and suggests the possibility of genetic transmission. A genetic transmission of supraventricular tachycardia has been described only in rare cases for the Wolff-Parkinson-White syndrome. No such data is available for the Mahaim syndrome.

Assessment of QT liabilities in drug development

Since the publication, in 1997, of the CPMP (Committee for Proprietary Medicinal Products) Points to Consider document on "The assessment of potential for QT prolongation by non-cardiovascular medicinal products," both regulatory bodies and the pharmaceutical industry have paid increasing attention to the conduct of careful preclinical studies on the subject. Regulatory attention has focused on the drafting of Safety Pharmacology guidelines through the ICH (International Conference on Harmonization) process, which resulted in approval by the ICH and acceptance by the three main regions (USA, Europe, and Japan) of the ICH S7A guideline. The guideline does not deal only with cardiovascular studies and does not provide guidance on QT investigations. This part has been deferred to a second guideline (ICH S7B). Nevertheless, pharmaceutical companies have implemented screening strategies aimed at selecting compounds that do not present QT liabilities. These strategies can differ according to the pharmaceutical class, while experimental models differ according to the stage of development of the compound. Several in vitro models are employed in discovery (radioligand binding, high-throughput patch clamp, efflux, and fluorescence assays). These models, coupled with in silico methods, allow companies to screen a high number of compounds. Other in vitro models, applied later in the R&D process (action potential duration, APD, in Purkinje fibers or papillary muscle and the isolated heart) are useful in better describing the activity of compounds on cardiac ion channels. The most robust and accepted in vivo test is represented by telemetry studies in conscious non-rodents.

Does pregnancy increase cardiac risk for LQT1 patients with the KCNQ1-A341V mutation?

OBJECTIVES

The purpose of this study was to assess the pregnancy-related cardiovascular risk in LQT1 patients.

BACKGROUND

Only 1 study addressed this issue in genotyped patients and reported that the highest risk is for LQT2 patients.

METHODS

This case-control study, performed in a cohort of patients from 22 families affected by LQT1 and all sharing the common KCNQ1-A341V mutation, involved 36 mutation carriers and 24 of their unaffected sisters for a total of 182 pregnancies.

RESULTS

There were 3 (2.6%) cardiac events (2 cardiac arrests) in the 115 LQT1 pregnancies. Because they occurred only among the 27 mothers with previous symptoms, all off-therapy, the risk for symptomatic patients is 11%, but decreases to 0 in symptomatic patients treated with beta-blockers. Carriers and control subjects did not differ for the incidence of miscarriage (10% vs. 15%). Cesarean sections (C-sections), elective or owing to fetal distress, were performed more often in carriers than in non-carriers (27% vs. 14%). Beta-blocker therapy did not influence the prevalence of fetal distress. Among the infants born to carriers, all those with fetal distress were carriers of the A341V mutation (10 of 10, 100%). Among the offspring of the carriers, 48 of 92 (52%) were mutation carriers, and of those, 15% died suddenly at age 14 +/- 6 years.

CONCLUSIONS

Women affected by the common KCNQ1-A341V mutation are at low risk for cardiac events during pregnancy and without excess risk of miscarriage; their infants delivered by C-section because of fetal distress are extremely likely to also be mutation carriers. Beta-blockers remain recommended. These conclusions likely apply to most LQT1 patients.

Potassium channels: new targets in cancer therapy

BACKGROUND

Potassium channels (KCh) are the most diverse and ubiquitous class of ion channels. KCh control membrane potential and contribute to nerve and cardiac action potentials and neurotransmitter release. KCh are also involved in insulin release, differentiation, activation, proliferation, apoptosis, and several other physiological functions. The aim of this review is to provide an updated overview of the KCh role during the cell growth. Their potential use as pharmacological targets in cancer therapies is also discussed.

METHODS

We searched PubMed (up to 2005) and identified relevant articles. Reprints were mainly obtained by on line subscription. Additional sources were identified through cross-referencing and obtained from Library services.

RESULTS

KCh are responsible for some neurological and cardiovascular diseases and for a new medical discipline, channelopathies. Their role in congenital deafness, multiple sclerosis, episodic ataxia, LQT syndrome and diabetes has been proven. Furthermore, a large body of information suggests that KCh play a role in the cell cycle progression, and it is now accepted that cells require KCh to proliferate. Thus, KCh expression has been studied in a number of tumours and cancer cells.

CONCLUSIONS

Cancer is far from being considered a channelopathy. However, it seems appropriate to take into account the involvement of KCh in cancer progression and pathology when developing new strategies for cancer therapy.

Congenital long QT syndromes: clinical features, molecular genetics and genetic testing

Congenital long QT syndrome (LQTS) is a primary electrical disease characterized by a prolonged QT interval in the surface electrocardiogram and increased predisposition to a typical polymorphic ventricular tachycardia, termed Torsade de Pointes. Most patients with LQTS are asymptomatic and are diagnosed incidentally based on an electrocardiogram. Symptomatic patients may suffer from severe cardiac events, such as syncope and/or sudden cardiac death. Autosomal dominant forms are caused by heterozygous mutations in genes encoding the components of the ion channels. The autosomal recessive form with congenital deafness is also known as Jervell and Lang-Nielsen syndrome. It is caused by homozygous mutations or certain compound heterozygous mutations. Depending on the genetic defects, there are differences in the age of onset, severity of symptoms, and number of cardiac events and event triggers. With advances in gene technology, it is now feasible to perform genetic testing for LQTS, especially for those with family history. Identification of the mutation will lead to better management of symptoms and more targeted treatment, depending on the underlying genetic defect, resulting in a reduction of mortality and cardiac events.

Temperature dependence of human ether-à-go-go-related gene K+ currents

The function of voltage-gated human ether-à-go-gorelated gene ( hERG) K+ channels is critical for both normal cardiac repolarization and suppression of arrhythmias initiated by premature excitation. These important functions are facilitated by their unusual kinetics that combine relatively slow activation and deactivation with rapid and voltage-dependent inactivation and recovery from inactivation. The thermodynamics of these unusual features were examined by exploring the effect of temperature on the activation and inactivation processes of hERG channels expressed in Chinese hamster ovary cells. Increased temperature shifted the voltage dependence of activation in the hyperpolarizing direction but that of inactivation in the depolarizing direction. This increases the relative occupancy of the open state and contributes to the marked temperature sensitivity of hERG current magnitude observed during action potential voltage clamps. The rates of activation and deactivation also increase with higher temperatures, but less markedly than do the rates of inactivation and recovery from inactivation. Our results also emphasize that one cannot extrapolate results obtained at room temperature to 37°C by using a single temperature scale factor.

Jervell-Lange Nielsen syndrome in a family with the long QT Syndrome (LQTS)

A child with Jervell-Lange Nielsen syndrome is presented from Kolkata. Family study showed that the other family members are suffering from long QT syndrome. The child had frequent syncopal attack and very prolonged QT interval requiring left cardiac sympathetic denervation and beta-blocker therapy as patient could not afford implantable defibrillator and cardiac pacing.

Modern management of arrhythmias

The specialist management of arrhythmias has changed significantly over the past decade. This article outlines current management strategies for atrial flutter and atrial fibrillation, with particular emphasis on curative strategies with catheter ablation and the recent data on rhythm compared with rate control strategies. The expanding role of catheter ablation in the treatment of a wide variety of supraventricular and ventricular arrhythmias is discussed. The current evidence for implantable cardioverter defibrillators in the prevention of sudden cardiac death is summarised. The article also highlights the increasing recognition of a number of inherited syndromes that predispose to sudden cardiac death (for example, Brugada and long QT syndromes).

The long QT syndrome family of cardiac ion channelopathies: A HuGE review*

Long QT syndrome (LQTS) refers to a group of "channelopathies"-disorders that affect cardiac ion channels. The "family" concept of syndromes has been applied to the multiple LQTS genotypes, LQT1-8, which exhibit converging mechanisms leading to QT prolongation and slowed ventricular repolarization. The 470+ allelic mutations induce loss-of-function in the passage of mainly K+ ions, and gain-of-function in the passage of Na+ ions through their respective ion channels. Resultant early after depolarizations can lead to a polymorphic form of ventricular tachycardia known as torsade de pointes, resulting in syncope, sudden cardiac death, or near-death (i.e., cardiac arrest aborted either spontaneously or with external defibrillation). LQTS may be either congenital or acquired. The genetic epidemiology of both forms can vary with subpopulation depending on the allele, but as a whole, LQTS appears in every corner of the globe. Many polymorphisms, such as HERG P448R and A915V in Asians, and SCN5A S1102Y in African Americans, show racial-ethnic specificity. At least nine genetic polymorphisms may enhance susceptibility to drug-induced arrhythmia (an "acquired" form of LQTS). Studies have generally demonstrated greater QT prolongation and more severe outcomes among adult females. Gene-gene interactions, e.g., between SCN5A Q1077del mutations and the SCN5A H558B polymorphism, have been shown to seriously reduce ion channel current. While phenotypic ascertainment remains a mainstay in the clinical setting, SSCP and DHPLC-aided DNA sequencing are a standard part of mutational investigation, and direct sequencing on a limited basis is now commercially available for patient diagnosis.

Effect of ciprofloxacin and levofloxacin on the QT interval: is this a significant "clinical" event?

BACKGROUND

The widespread use of the fluoroquinolones has raised the question of the cardiac safety of these medications. This widespread use of this class of antibiotics has displayed their safety profile, which is actually more favorable than many other drug classes. The cardiac toxicity issue at the center of this discussion is the prolongation of the QT interval leading to torsade de pointes. Ciprofloxacin and levofloxacin, two of the more commonly used fluoroquinolones, are considered less likely than other fluoroquinolones to prolong the QT interval. The authors set out to evaluate the effect on the QT interval of patients after administration of ciprofloxacin and levofloxacin.

METHODS

A prospective evaluation of 38 consecutive patients evaluated by the infectious disease service and receiving either ciprofloxacin or levofloxacin was undertaken. Twelve-lead electrocardiograms were obtained at baseline and at least 48 hours after the first dose of the antibiotic was administered. Both the longest QT interval and the mean QT interval were evaluated. To account for variations in heart rate, the corrected QT interval was calculated by using Bazett's formula (QTc = QT(square root of) R-R). Statistical analysis was undertaken to assess for the presence of a change after the administration of the antibiotic.

RESULTS

Thirty-eight patients (mean age, 65 +/- 19 years), 23 women and 15 men, were studied. There was a small but significant increase in the longest QTc intervals over baseline in patients receiving levofloxacin; there was no significant change in the mean QTc interval. However, one patient who received levofloxacin was, statistically, an outlier and, on retrospective analysis, had demonstrated severe electrolyte disturbances at the time of the study. When this patient was excluded, the increase in the longest QTc interval was not significant. Patients receiving ciprofloxacin did not demonstrate any significant change in the longest QTc interval or mean QTc interval.

CONCLUSIONS

Neither levofloxacin nor ciprofloxacin significantly prolonged the mean QTc interval over baseline. When electrolyte deficiencies in one of the patients evaluated were taken into account, this also held true for the longest QTc interval. There is, therefore, evidence that taking ciprofloxacin or levofloxacin, assuming that there are not any concurrent risk factors, will not cause a significant prolongation in the QT interval.

Cardiac arrhythmias and sudden death in infancy: implication for the medicolegal investigation

Genetically transmitted diseases are an important cause of juvenile sudden cardiac death (SCD). In a considerable proportion of individuals in which a medicolegal investigation is performed, structural heart disease is absent, and the medical examiner fails to discover an adequate cause of death. In such cases, an inherited arrhythmogenic disease should be considered, which manifests with life-threatening ventricular tachycardia or SCD. Molecular diagnosis is progressively becoming an important tool for these questions. Therefore, postmortem genetic testing ("molecular autopsy") should be considered as a part of the comprehensive medicolegal investigation in SCD cases without apparent structural heart disease. It will have implications not only for the deceased individual but also for living family members in preventing (further) cardiac events by expert counseling, appropriate lifestyle adjustment, and adequate treatment, if available.

Topics on the Na+/Ca2+ Exchanger: Involvement of Na+/Ca2+ Exchange System in Cardiac Triggered Activity

Sodium-calcium exchange (NCX) is one of the major regulators of intracellular Ca(2+) concentration in cardiac myocytes. The bi-directional and electrogenic property of NCX raises a question about whether NCX is involved in arrhythmias. We reviewed the role of NCX in cardiac triggered activity in limited experimental conditions: the digitalis-induced arrhythmia, the arrhythmia caused from sustained opening of sodium channel, and the arrhythmia caused from the inhibition of inwardly rectifying potassium current. Effects of NCX inhibitors on ventricular arrhythmias recorded on ECG or the delayed afterdepolarizations and triggered activity recorded by the current clamp method were evaluated. As an NCX inhibitor, we preferred to use SEA0400 instead of KB-R 7943. For a precise analysis, a computational reconstruction of action potential with the Luo and Rudy model was applied. The cardiac NCX system seems to play a role only in the digitalis-induced arrhythmia and may not be involved in other arrhythmias. This review highlights the relationship between triggered activity and an NCX system and also suggests the physiologic and pathologic aspect of the NCX system in cardiac arrhythmias.

Use of autonomic maneuvers to probe phenotype/genotype discordance in congenital long QT syndrome

Patients with congenital long QT syndrome due to potassium channel mutations (LQT1 and LQT2) may elude diagnosis due to normal electrocardiographic findings at rest, yet remain at risk of sudden death during bradycardia or sympathetic stimulation. To test the hypothesis that autonomic maneuvers can unmask long QT syndrome in genetically abnormal subjects with a normal phenotype (QTc < or =450 ms), we exposed 13 controls (33 +/- 9 years; 5 men), 5 patients with LQT1 (32 +/- 12 years; 3 men), and 5 patients with LQT2 (30 +/- 11 years; 5 men) to phenylephrine bolus, exercise, and epinephrine infusion. The QT interval was measured at baseline and after each intervention. A substantial overlap was found in QTc among the groups at baseline and after phenylephrine. In contrast, QTc was significantly and consistently longer in subjects with LQT1 compared with controls during and after exercise (492 +/- 40 vs 407 +/- 14 ms, p <0.0001, at peak exercise; 498 +/- 30 vs 399 +/- 20 ms, p <0.0001, at 1 minute into recovery) or epinephrine (623 +/- 51 vs 499 +/- 51 ms, p <0.001, at peak epinephrine; 604 +/- 36 vs 507 +/- 54 ms, p <0.01, at 1 minute into recovery) but not in subjects with LQT2. In conclusion, sympathetic stimulation can reveal the LQT1 phenotype even in subjects with normal baseline electrocardiographic findings.

Effects of Methadone on QT-Interval Dispersion

STUDY OBJECTIVE

To evaluate the effects of methadone on QT-interval dispersion.

DESIGN

Single-center, prospective, cohort study.

SETTING

Methadone maintenance treatment facility.

PATIENTS

One hundred eighteen patients who were newly admitted to the facility. Intervention. Twelve-lead electrocardiograms (ECGs) were performed in patients at both baseline and 6 months after the start of methadone therapy.

MEASUREMENTS AND MAIN RESULTS

The ECGs were manually interpreted, and investigators were blinded to time interval and methadone dose. At least eight discernible ECG leads were required for study inclusion. Mean differences between baseline and follow-up rate-corrected QT (QTc) interval and QT dispersion were compared. Multivariate associations between clinical characteristics and magnitude of change in QT dispersion were assessed using linear regression. Mean +/- SD baseline QT dispersion was 32.9 +/- 12 msec, which increased to 42.4 +/- 15 msec (+9.5 +/- 18.6 msec, p<0.0001) after 6 months of therapy. The QTc increased by a similar magnitude (+14.1 msec, p<0.0001). No QT dispersion value exceeded 100 msec. The only variable associated with a greater increase in QT dispersion was antidepressant therapy (20 vs 8.5 msec, p=0.04).

CONCLUSION

Methadone modestly increased both QTc interval and QT dispersion. Increased QT dispersion reflects heterogeneous cardiac repolarization and occurs with nonantiarrhythmic agents, such as synthetic opioids. However, the magnitude of this effect appears to be substantially less with methadone than with antiarrhythmic drugs.

Diagnosis of unexplained cardiac arrest: role of adrenaline and procainamide infusion

BACKGROUND

Cardiac arrest with preserved left ventricular function may be caused by uncommon genetic conditions. Although these may be evident on the ECG, long-term monitoring or provocative testing is often necessary to unmask latent primary electrical disease.

METHODS AND RESULTS

Patients with unexplained cardiac arrest and no evident cardiac disease (normal left ventricular function, coronary arteries, and resting corrected QT) underwent pharmacological challenge with adrenaline and procainamide infusions to unmask subclinical primary electrical disease. Family members underwent noninvasive screening and directed provocative testing on the basis of findings in the proband. Eighteen patients (mean+/-SD age, 41+/-17 years; 11 female) with unexplained cardiac arrest were assessed. The final diagnosis was catecholaminergic ventricular tachycardia (CPVT) in 10 patients (56%), Brugada syndrome in 2 patients (11%), and unexplained (idiopathic ventricular fibrillation) in 6 patients (33%). Of 55 family members (mean+/-SD age, 27+/-17 years; 33 female), 9 additional affected family members were detected from 2 families, with a single Brugada syndrome patient and 8 CPVT patients.

CONCLUSIONS

Provocative testing with adrenaline and procainamide infusions is useful in unmasking the etiology of apparent unexplained cardiac arrest. This approach helps to diagnose primary electrical disease, such as CPVT and Brugada syndrome, and provides the opportunity for therapeutic intervention in identified, asymptomatic family members who harbor the same disease.

Propranolol inhibits the human ether-a-go-go-related gene potassium channels

Propranolol is a noncardioselective beta-adrenergic antagonist that has been recently reported to prolong the QTc interval on the surface electrocardiogram in humans when overdosed [Farhangi, V., Sansone, R.A. (2003). QTc prolongation due to propranolol overdose. Int. J. Psychiatry Med. 33, 201-202.]. To examine the underlying mechanisms for these clinical findings, we studied the effects of propranolol on the human cardiac potassium channels encoded by the ether-a-go-go-related gene (ERG) using the whole cell voltage-clamp technique. We found that propranolol blocked hERG currents in a concentration-dependent manner with an IC50 of 9.9+/-1.3 microM which is relevant to the predicted plasma level of propranolol in this case report. The present study demonstrated that propranolol can inhibit hERG channels. The interaction between propranolol and hERG channels could lead to delayed cardiac repolarization and might be a molecular mechanism for the previously reported QTc prolongation when propranolol is overdosed.

Improved diagnostic effectiveness with a sequential diagnostic paradigm in idiopathic pediatric sensorineural hearing loss

OBJECTIVES

To determine whether a stepwise diagnostic paradigm is more diagnostically efficient and cost-effective than a simultaneous testing approach in the evaluation of idiopathic pediatric sensorineural hearing loss (SNHL).

DESIGN

Prospective prevalence study.

SETTING

Tertiary referral children's hospital.

PATIENTS

Consecutive children (n = 150) presenting with idiopathic SNHL in the last 2 years.

INTERVENTIONS

All children were evaluated with full diagnostic evaluations including GJB2 screens, temporal bone computed tomography scans, and laboratory investigations.

MAIN OUTCOME MEASURES

1) Diagnostic yields of GJB2 screens, imaging, and laboratory results per SNHL category; 2) Cost analysis comparing a sequential versus a simultaneous testing approach.

RESULTS

Overall, 12.0% of patients had biallelic mutations in the GJB2 gene, whereas 30% of patients had an abnormality on temporal bone scan. Laboratory testing did not reveal the SNHL etiology in any patient. While maintaining diagnostic accuracy, significant cost savings were inferred by using a sequential diagnostic algorithm. Our data show children with severe to profound SNHL should first be tested with a GJB2 screen, as opposed to those with milder SNHL, who should undergo imaging as the initial testing step. In patients with initially positive GJB2 or imaging screens, logistic regression analysis significantly predicted negative results on further testing.

CONCLUSIONS

A stepwise diagnostic paradigm tailored to the level of the hearing loss in children with bilateral SNHL is more diagnostically efficient and cost effective than the more commonly used full, simultaneous testing approach. Laboratory investigation should not be routine but based on clinical history.

QRST isointegral departure mapping after exercise in patients with congenital long QT syndrome

Congenital long QT syndrome (LQTS) is known to be a critical syndrome associated with a bizarre T wave, prolonged QT interval, and ventricular arrhythmias and is followed by syncope and/or sudden death. Body surface mapping, especially QRST isointegral departure mapping, was used after exercise to assess exercise-induced repolarization changes in patients with this syndrome. This study included 12 patients with the Romano-Ward syndrome (LQTS group, 9 women, 30 +/- 19 years) and 19 healthy adults (control group, 5 women, 24 +/- 5 years). In the LQTS group, there was a significant increase in the number of local extrema and abnormal points after exercise in the departure maps. In the LQTS group, QRST isointegral departure mapping presented more marked abnormalities of repolarization after an exercise stress test. In mild cases that revealed abnormalities only after the exercise stress, such testing may be helpful for LQTS diagnosis.

Drugs effects on ventricular repolarization: A critical evaluation of the strengths and weaknesses of current methodologies and regulatory practices

A growing number of drugs and drug combinations inhibit cardiac potassium ion conductance and ventricular repolarization, and increase cardiac APD, QT interval, and risk of potentially fatal TdP. The past decade has seen an explosion of research advances into the mechanism of action underpinning these observations, and an unprecedented level of collaboration between academia, industry, and regulatory authorities to define effective strategies for accurate prediction of increased TdP risk (if any) in humans, based upon nonclinical and/or clinical endpoints. Because the incidence of TdP is so very low, even for drugs for which the association is known, the risk can only be assessed based upon surrogate markers (signals) in in vitro and in vivo non-clinical studies as well as in clinical trials. In this article, we review both the strengths and weaknesses of current methodologies and regulatory practices for assessment of TdP risk for pharmaceuticals.

Automated electrophysiology in the preclinical evaluation of drugs for potential QT prolongation

INTRODUCTION

The human ether-a-go-go-related gene (hERG) potassium channel plays a major role in the electrical conductances involved in human heart repolarization. Drugs that decrease hERG K(+) currents are at risk to produce a prolongation of the cardiac action potential, resulting in an increase of the QT interval. Drug-induced QT prolongation or acquired long QT (aLQT) can lead to a fatal arrhythmia known as Torsade de Pointes (TdP). Electrophysiological methods are the best approach to evaluate potential drug candidates for hERG current inhibition. Here we identify limitations with the PatchXpress 7000A automated electrophysiology instrument and describe hERG protocol optimizations necessary for reliable preclinical assessment.

METHODS

The PatchXpress 7000A automated electrophysiology system was used to evaluate a group of drugs with known hERG activity under voltage clamp conditions. We used a recombinant cell line expressing hERG, and assessed the inhibition of hERG K(+) currents at different drug concentrations. These data were used to determine hERG IC(50) values and compare assay parameters under different recording conditions.

RESULTS

We found that due to limitations with the PatchXpress 7000A instrument, repeated compound additions were critical for achieving steady state drug concentrations that generated data comparable to standard patch clamp methods, particularly when similar voltage pulse protocols were implemented. Some discrepancies were observed between the PatchXpress 7000A and standard patch clamp techniques including shifts in IC(50) values for very hydrophobic compounds. Most hERG IC(50) values were within 3-fold of standard patch clamp IC(50) values.

DISCUSSION

Automation of electrophysiology technologies has greatly improved the throughput of assessing lead drug candidates for hERG liability. To maintain hERG data quality comparable to standard patch clamp techniques, the PatchXpress 7000A instrument limitations should be recognized and protocols optimized accordingly to ensure accuracy.

Reduced voltage dependence of inactivation in the SCN5A sodium channel mutation delF1617

Deletion of a phenylalanine at position 1617 (delF1617) in the extracellular linker between segments S3 and S4 in domain IV of the human heart Na+ channel (hH1a) has been tentatively associated with long QT syndrome type 3 (LQT3). In a mammalian cell expression system, we compared whole cell, gating, and single-channel currents of delF1617 with those of wild-type hH1a. The half points of the peak activation-voltage curve for the two channels were similar, as were the deactivation time constants at hyperpolarized test potentials. However, delF1617 demonstrated a significant negative shift of −7 mV in the half point of the voltage-dependent Na+ channel availability curve compared with wild type. In addition, both the time course of decay of Na+ current ( INa) and two-pulse development of inactivation of delF1617 were faster at negative test potentials, whereas they tended to be slower at positive potentials compared with wild type. Mean channel open times for delF1617 were shorter at potentials <0 mV, whereas they were longer at potentials >0 mV compared with wild type. Using anthopleurin-A, a site-3 toxin that inhibits movement of segment S4 in domain IV (S4-DIV), we found that gating charge contributed by the S4-DIV in delF1617 was reduced 37% compared with wild type. We conclude that deletion of a single amino acid in the S3-S4 linker of domain IV alters the voltage dependence of fast inactivation via a reduction in the gating charge contributed by S4-DIV and can cause either a gain or loss of INa, depending on membrane potential.

Specificity of TRH receptor coupling to G-proteins for regulation of ERG K+ channels in GH3 rat anterior pituitary cells

The identity of the G-protein coupling thyrotropin-releasing hormone (TRH) receptors to rat ether-à-go-go related gene (r-ERG) K+ channel modulation was studied in situ using perforated-patch clamped adenohypophysial GH(3) cells and dominant-negative variants (Galpha-QL/DN) of G-protein alpha subunits. Expression of dominant-negative Galpha(q/11) that minimizes the TRH-induced Ca2+ signal had no effect on r-ERG current inhibition elicited by the hormone. In contrast, the introduction of dominant-negative variants of Galpha13 and the small G-protein Rho caused a significant loss of the inhibitory effect of TRH on r-ERG. A strong reduction of this TRH effect was also obtained in cells expressing either dominant-negative Galpha(s) or transducin alpha subunits, an agent known to sequester free G-protein betagamma dimers. As a further indication of specificity of the dominant-negative effects, only the dominant-negative variants of Galpha13 and Rho (but not Galpha(s)-QL/DN or Galpha(t)) were able to reduce the TRH-induced shifts of human ERG (HERG) activation voltage dependence in HEK293 cells permanently expressing HERG channels and TRH receptors. Our results demonstrate that whereas the TRH receptor uses a G(q/11) protein for transducing the Ca2+ signal during the initial response to TRH, this G-protein is not involved in the TRH-induced inhibition of endogenous r-ERG currents in pituitary cells. They also identify G(s) (or a G(s)-like protein) and G13 as important contributors to the hormonal effect in these cells and suggest that betagamma dimers released from these proteins may participate in modulation of ERG currents triggered by TRH.

A survey of health care practitioners' knowledge of the QT interval

OBJECTIVE

To assess health care practitioners' ability to correctly measure the QT interval, and to identify factors and medications that may increase the risk of QT-interval prolongation and torsades de pointes.

DESIGN

A cross-sectional analysis of a survey administered between April 2002 and March 2003.

PARTICIPANTS AND SETTING

Health care practitioners attending Grand Rounds Conferences at 6 academic institutions in the United States in internal medicine and psychiatry and at 6 community hospitals in the same geographical areas as the academic institutions.

INTERVENTION

Anonymous, self-administered questionnaire that included 20 questions on the QT interval.

MEASUREMENTS AND MAIN RESULTS

Of approximately 826 attendees, 517 (63%) completed the survey. Of about 608 attendees of internal medicine conferences, 371 (61%) responded, and of about 208 attendees of psychiatry conferences, 146 (67%) responded. Of a total number of 20 questions, the median number of correct answers for the whole group was 10 (interquartile range 7-13). The median number of correct answers for internists was 12 (interquartile range 9-13), for psychiatrists 10 (interquartile range 7-13), and for other specialists 10 (interquartile range 5-13). Respondents who graduated between 1990 and 1999 and academicians performed significantly better overall than other respondents. Of the 517 respondents, 224 (43%) measured the QT interval correctly. Physicians in training and academicians were more likely to measure the QT interval correctly.

CONCLUSION

The majority of health care practitioners cannot correctly measure the QT interval and cannot correctly identify factors and medications that can prolong the QT interval. Our findings suggest that greater attention to the QT interval is warranted to ensure safer use of QT prolonging medications.

Assessment of ventricular repolarization in a large group of children with early onset deafness

This study examined the ECG traces of 397 deaf children (age 12.5 +/- 2.9 years, range 6-19 years), after exclusion of cases with Jervell and Lange-Nielsen syndrome (JLNS), and compared them to those of 361 normal hearing counterparts (age 12.5 +/- 2.7 years; range 7-18 years). An observer, who was unaware of the hearing status of the subjects, measured QT and QTc intervals and calculated dispersions of QT and QTc from standard 12-lead ECGs recorded at a speed of 25 mm/s at rest. Although the mean QT was found to be longer in deaf children than that observed in the control group (P < 0.0001), the mean QTc was significantly shorter (P < 0.0001). The mean heart rate was significantly lower in deaf children. When QT and QTc data were recompared after the children were grouped according to the heart rate, the observed difference became less significant or disappeared. In conclusion, there are no major abnormalities for repolarization parameters in children with congenital sensorineural deafness, when compared to hearing counterparts, if heart rates are similar. Based on these results, routine ECG screening of deaf children for repolarization abnormalities may be unnecessary unless they have a history of syncope or positive family history of syncope and/or early sudden death.

Inhibition of L-type Ca(2+) current in Guinea pig ventricular myocytes by cisapride

The effect of cisapride on L-type Ca(2+) current (I(Ca,L)) was studied in guinea pig ventricular myocytes using a whole-cell voltage-clamp technique and a conventional action potential recording method. Myocytes were held at -40 mV, and internally dialyzed and externally perfused with Na(+)- and K(+)-free solutions; cisapride elicited a concentration-dependent block of peak I(Ca,L), with a half-maximum inhibition concentration (IC(50)) of 46.9 microM. There was no shift in the reversal potential, nor any change in the shape of the current-voltage relationship of I(Ca,L) in the presence of cisapride. Inhibition of cisapride was not associated with its binding to serotonin or to alpha-adrenergic receptors because ketanserin, SB203186, and prazosin had no effect on the inhibitory action of cisapride on I(Ca,L). Cisapride elicited a tonic block and a use-dependent block of I(Ca,L). These blocking effects were voltage dependent as the degree of inhibition at -40 mV was greater than that at -70 mV. Cisapride shifted the steady-state inactivation curve of I(Ca,L) in the negative direction, but had no effect on the steady-state activation curve. Cisapride also delayed the kinetics of recovery of I(Ca,L) from inactivation. At a slow stimulation frequency (0.1 Hz), the action potential duration in guinea pig papillary muscles showed biphasic effects; it was prolonged by lower concentrations of cisapride, but shortened by higher concentrations. These findings suggest that cisapride preferentially binds to the inactivated state of L-type Ca(2+) channels. The inhibitory effect of cisapride on I(Ca,L) might play an important role in its cardiotoxicity under pathophysiological conditions, such as myocardial ischemia.

Novel C-terminus frameshift mutation, 1122fs/147, of HERG in LQT2: additional amino acids generated by frameshift cause accelerated inactivation

OBJECTIVE

The function of the C-terminus region of the human ether-a-go-go related gene (HERG) has not been well characterized except for its involvement in trafficking. To understand further the role of C-terminus region, we performed a functional analysis of a novel frameshift mutation (1122fs/147) identified in a Japanese long QT syndrome 2 (LQT2) patient who had recurrent episodes of syncope.

METHODS

Wild type (WT) and mutant HERG plasmids were transfected into human embryonic kidney (HEK-293) cells, and whole-cell current was recorded by the patch-clamp technique. Confocal microscopy was performed to examine the membrane distribution of channel protein using a green fluorescent protein tagged to the N-terminus of HERG.

RESULTS

The mutant 1122fs/147 alone could express current, but reduced density by 74% of control. No dominant negative effect was noted with co-expression of WT and 1122fs/147. Activation and deactivation time constants were not changed, while inactivation was accelerated in 1122fs/147 compared to WT, and V(1/2) of steady-state inactivation curve shifted by 11 mV in the negative direction. Current density of 1123stop mutant revealed 49% reduction compared to WT and showed no shift in steady-state inactivation. Confocal microscopy revealed reduced protein expression on the cell surface both in 1122fs/147 and 1123stop mutants compared to WT.

CONCLUSION

Frameshift mutation at the C-terminus region with additional 147 amino acids evoked a loss of function of the HERG channel. A negative shift in steady-state inactivation induced by the additional 147 amino acids and trafficking defect contribute to a reduced current amplitude of 1122fs/147.

Identification of a KCNE2 gain-of-function mutation in patients with familial atrial fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice. We first reported an S140G mutation of KCNQ1, an alpha subunit of potassium channels, in one Chinese kindred with AF. However, the molecular defects and cellular mechanisms in most patients with AF remain to be identified. We evaluated 28 unrelated Chinese kindreds with AF and sequenced eight genes of potassium channels (KCNQ1, HERG, KCNE1, KCNE2, KCNE3, KCNE4, KCNE5, and KCNJ2). An arginine-to-cysteine mutation at position 27 (R27C) of KCNE2, the beta subunit of the KCNQ1-KCNE2 channel responsible for a background potassium current, was found in 2 of the 28 probands. The mutation was present in all affected members in the two kindreds and was absent in 462 healthy unrelated Chinese subjects. Similar to KCNQ1 S140G, the mutation had a gain-of-function effect on the KCNQ1-KCNE2 channel; unlike long QT syndrome-associated KCNE2 mutations, it did not alter HERG-KCNE2 current. The mutation did not alter the functions of the HCN channel family either. Thus, KCNE2 R27C is a gain-of-function mutation associated with the initiation and/or maintenance of AF.

QT prolongation with antimicrobial agents: understanding the significance

Cardiac toxicity has been relatively uncommon within the antimicrobial class of drugs, but well described for antiarrhythmic agents and certain antihistamines. Macrolides, pentamidine and certain antimalarials were traditionally known to cause QT-interval prolongation, and now azole antifungals, fluoroquinolones and ketolides can be added to the list. Over time, advances in preclinical testing methods for QT-interval prolongation and a better understanding of its sequelae, most notably torsades de pointes (TdP), have occurred. This, combined with the fact that five drugs have been removed from the market over the last several years, in part because of QT-interval prolongation-related toxicity, has elevated the urgency surrounding early detection and characterisation methods for evaluating non-antiarrhythmic drug classes. With technological advances and accumulating literature regarding QT prolongation, it is currently difficult or overwhelming for the practising clinician to interpret these data for purposes of formulary review or for individual patient treatment decisions. Certain patients are susceptible to the effects of QT-prolonging drugs. For example, co-variates such as gender, age, electrolyte derangements, structural heart disease, end organ impairment and, perhaps most important, genetic predisposition, underlie most if not all cases of TdP. Between and within classes of drugs there are important differences that contribute to delayed repolarisation (e.g. intrinsic potency to inhibit certain cardiac ion currents or channels, and pharmacokinetics). To this end, a risk stratification scheme may be useful to rank and compare the potential for cardiotoxicity of each drug. It appears that in most published cases of antimicrobial-associated TdP, multiple risk factors are present. Macrolides in general are associated with a greater potential than other antimicrobials for causing TdP from both a pharmacodynamic and pharmacokinetic perspective. The azole antifungal agents also can be viewed as drugs that must be weighed carefully before use since they also have both pharmacodynamic and pharmacokinetic characteristics that may trigger TdP. The fluoroquinolones appear less likely to be associated with TdP from a pharmacokinetic perspective since they do not rely on cytochrome P450 (CYP) metabolism nor do they inhibit CYP enzyme isoforms, with the exception of grepafloxacin and ciprofloxacin. Nonetheless, patient selection must be carefully made for all of these drugs. For clinicians, certain responsibilities are assumed when prescribing antimicrobial therapy: (i) appropriate use to minimise resistance; and (ii) appropriate patient and drug selection to minimise adverse event potential. Incorporating information learned regarding QT interval-related adverse effects into the drug selection process may serve to minimise collateral iatrogenic toxicity.

Congenital and Acquired Long QT Syndrome

Congenital long QT syndrome (LQTS) is a rare but potentially lethal disease, characterized by prolongation of QT interval, recurrent syncope, and sudden death. In the pregenomic era (1959-1991), sympathetic imbalance was thought to be responsible for this disease. Since 1991 (postgenomic era), 7 LQTS genes have been discovered and more than 300 mutations have been identified to account for approximately 70% of patients affected. Despite the advancement in molecular genetic knowledge, diagnosis of congenital LQTS is still based on electrocardiographic and clinical characteristics. Beta-blockers remain the mainstay treatment. For high-risk patients, the implantable cardioverter-defibrillator (ICD) offer an effective therapeutic option to reduce mortality. Gene-based specific therapy is still preliminary. Further studies are required to investigate new strategies for targeting the defective genes or mutant channels. For acquired LQTS, it is generally believed that the main issue is the blockade of the slow component of the delayed rectifier K+ current (IKr). These IKr blockers have a "reverse frequency-dependent" effect on the QTc interval and increase the dispersion in repolarization. In the presence of risk factors such as female gender, slow heart rate, and hypokalemia, these IKr blockers have a high propensity to induce torsades de pointes. For patients with a history of drug-induced LQTS, care must be taken to avoid further exposure to QT-prolonging drugs or conditions. Molecular genetic analysis could be useful to unravel subclinical mutations or polymorphisms. Physicians not only need to be aware of the pharmacodynamic and pharmacokinetic interactions of various important drugs, but also need to update their knowledge.

A cardiac arrhythmia syndrome caused by loss of ankyrin-B function

220-kDa ankyrin-B is required for coordinated assembly of Na/Ca exchanger, Na/K ATPase, and inositol trisphosphate (InsP(3)) receptor at transverse-tubule/sarcoplasmic reticulum sites in cardiomyocytes. A loss-of-function mutation of ankyrin-B identified in an extended kindred causes a dominantly inherited cardiac arrhythmia, initially described as type 4 long QT syndrome. Here we report the identification of eight unrelated probands harboring ankyrin-B loss-of-function mutations, including four previously undescribed mutations, whose clinical features distinguish the cardiac phenotype associated with loss of ankyrin-B activity from classic long QT syndromes. Humans with ankyrin-B mutations display varying degrees of cardiac dysfunction including bradycardia, sinus arrhythmia, idiopathic ventricular fibrillation, catecholaminergic polymorphic ventricular tachycardia, and risk of sudden death. However, a prolonged rate-corrected QT interval was not a consistent feature, indicating that ankyrin-B dysfunction represents a clinical entity distinct from classic long QT syndromes. The mutations are localized in the ankyrin-B regulatory domain, which distinguishes function of ankyrin-B from ankyrin-G in cardiomyocytes. All mutations abolish ability of ankyrin-B to restore abnormal Ca(2+) dynamics and abnormal localization and expression of Na/Ca exchanger, Na/K ATPase, and InsP(3)R in ankyrin-B(+/-) cardiomyocytes. This study, considered together with the first description of ankyrin-B mutation associated with cardiac dysfunction, supports a previously undescribed paradigm for human disease due to abnormal coordination of multiple functionally related ion channels and transporters, in this case the Na/K ATPase, Na/Ca exchanger, and InsP(3) receptor.

Effects of the paralysis tick, Ixodes holocyclus, on the electrocardiogram of the Spectacled Flying Fox, Pteropus conspicillatus

OBJECTIVE

To evaluate cardiac electrical function in the Spectacled Flying Fox (bat) infested with Ixodes holocyclus.

DESIGN

Prospective clinical investigation of bats treated for naturally occurring tick toxicity.

PROCEDURE

ECGs were performed on bats with tick toxicity (n = 33), bats that recovered slowly (n = 5) and normally (n = 5) following treatment for tick toxicity, and on normal bats with no history of tick toxicity (n = 9).

RESULTS

Bats with tick toxicity had significantly prolonged corrected QT intervals, bradycardia and rhythm disturbances which included sinus bradydysrhythmia, atrial standstill, ventricular premature complexes, and idioventricular bradydysrhythmia.

CONCLUSIONS

The QT prolongation observed on ECG traces of bats with tick toxicity reflected delayed ventricular repolarisation and predisposed to polymorphic ventricular tachycardia and sudden cardiac death in response to sympathetic stimulation. The inability to document ventricular tachycardia in bats shortly before death from tick toxicity may be explained by a lack of sympathetic responsiveness attributable to the unique parasympathetic innervation of the bat heart, or hypothermia-induced catecholamine receptor down-regulation. Bradycardia and rhythm disturbances may be attributable to hypothermia.

Is prolongation of the QTc interval during isoflurane anaesthesia more prominent in women pretreated with anthracyclines for breast cancer? †

BACKGROUND

Inhalation anaesthetics and anthracycline chemotherapeutic drugs may both prolong the QT interval of the electrocardiogram. We investigated whether isoflurane may induce or augment QTc prolongation in patients who had previously received cancer chemotherapy including anthracycline drugs.

METHODS

Forty women undergoing surgery for breast cancer were included in the study. They were divided into two groups: (A) women previously treated with anthracyclines (n=20); and (B) women not treated with antineoplastic drugs (n=20). All patients received a standardized balanced anaesthetic in which isoflurane 0.5 vol% was used. The QT and corrected QT intervals were measured before anaesthesia, after induction and tracheal intubation, after 1, 5, 15, 30, 60 and 90 min of anaesthesia, and during recovery.

RESULTS

In both groups we observed a tendency to QTc prolongation, but statistically significant differences among baseline values and values observed during isoflurane-containing anaesthesia were seen only in group A. During anaesthesia, significant differences in QTc values between the two groups were observed.

CONCLUSION

In female patients pretreated with anthracyclines for breast cancer, the tendency to QTc prolongation during isoflurane-containing general anaesthesia was more strongly expressed than in patients without previous chemotherapy.

Block of recombinant KCNQ1/KCNE1 K+ channels (IKs) by intracellular Na+ and its implications on action potential repolarization

I(Ks), the slow component of delayed rectifier K+ current, plays an important role for the repolarization of ventricular action potential. We investigated the block of I(Ks) by intracellular Na+ ([Na+](i)), using a heterologous expression system (KCNQ1/KCNE1 expressed in COS7 cells), since this well-known blocking action on various K+ channels has not been fully or quantitatively characterized in I(Ks) current. The Na+ block of I(Ks) was concentration- and voltage-dependent and was described by a conventional binding-site model (Woodhull AM: J Gen Physiol 61: 687-708, 1973). In physiological ionic conditions, the blocking action was operating noticeably with Delta ("electrical" distance of the block site) approximately 0.6 and K(d)(0) (apparent dissociation constant at 0 mV) approximately 300 mM. Because K(d)(0) was a function of intra- and extracellular K+ concentrations, changes in ionic environments not only of [Na+](i), but also of [K+](o), affected the amplitude of I(Ks) through the modulation of the Na+ block. Based on these experimental data, we analyzed the effects of Na+ block on action potentials by a computer simulation study, using the Luo-Rudy model. In a physiological ionic environment, the Na+ block of I(Ks) contributed little to modifying action potentials. However, when action potential duration (APD) was marginally prolonged because of decreased I(Ks), as observed in M cells under the conditions of bradycardia and low [K+](o), the Na+ block of I(Ks) may contribute to arrhythmogenesis through the facilitation of early afterdepolarizations (EADs).

Effect of phenylephrine provocation on dispersion of repolarization in congenital long QT syndrome

INTRODUCTION

Syncope and sudden death are associated with sympathetic stimulation in LQT1 while LQT2 patients are more susceptible to arrhythmias during nonexertional states. Abnormal spatial (QTd)- and transmural (TDR)-dispersion of repolarization may indicate increased arrhythmogenicity. This study compares the effect of phenylephrine on QTd and TDR in genotyped LQTS to control (C).

METHODS AND RESULTS

Seventeen LQT1, 12 LQT2, and 18 age- and sex-matched normal controls received 2 mcg/kg of phenylephrine intravenously. At baseline and peak phenylephrine effect, BP, QT, RR, Bazett's QTc, precordial QTd (QTmax-QTmin), and T-peak to T-end (Tp-e) intervals were determined blinded to the patient's clinical and genotype status. Baseline QT intervals and QTc were significantly longer in LQT1 and LQT2 compared to C. Baseline QTd and Tp-e were greater in LQT2 than either LQT1 or C: QTd=79+/-29 ms (LQT2), 53+/-26 (LQT1), and 45+/-15 (C) and Tp-e=120+/-30 ms (LQT2), 99+/-20 (LQT1), and 90+/-11 (C). Overall, phenylephrine exerted no significant effect on either QTd or Tp-e except with subgroup analysis of symptomatic LQTS where LQT1 and LQT2 patients had a divergent response with TDR.

CONCLUSIONS

Phenylephrine-induced bradycardia decreased TDR in symptomatic LQT1 but increased TDR in symptomatic LQT2. The observed effects of phenylephrine are consistent with the protective effect of beta-blocker in LQT1 and the increased arrhythmogenicity noted during nonexertional states in LQT2.

Effects of Sodium-Calcium Exchange Inhibitors, KB-R7943 and SEA0400, on Aconitine-Induced Arrhythmias in Guinea Pigs in Vivo, in Vitro, and in Computer Simulation Studies

The sodium-calcium exchange (NCX) plays a pivotal role in regulating contractility and electrical activity in the heart. However, the effects of NCX blockers on ventricular arrhythmias are still controversial. We examined the effects of KB-R7943 (KBR) and SEA0400 (SEA), two NCX blockers, on aconitine-induced arrhythmias in guinea pigs using the ECG recordings and the current-clamp method. Using Luo's and Rudy's computer model (1991 Circ Res 68:1501-1526) for ventricular myocytes, we simulated abnormal membrane activity produced by NCX inhibition. In the whole-animal model, KBR in a dose range of 1 to 30 mg/kg (intravenous) suppressed aconitine-induced arrhythmias dose-dependently, but 10 mg/kg of SEA did not suppress these arrhythmias. There was a difference in isolated ventricular myocytes also. KBR (10 microM) suppressed abnormal electrical activity induced by aconitine, but SEA (100 microM) did not show such effects. KBR (10 microM) significantly changed the shape of the action potential configurations (action potential duration at 50% repolarization), but SEA (1-100 microM) did not change these configurations. In the computer simulation study, the aconitine-induced abnormal electrical activity was mimicked by a negative shift of the kinetics of Na+ channels, and this was followed by additional suppression of NCX activity by 90% (mimicking the effect of NCX inhibitors), which enhanced abnormal membrane activity. Our results indicate that the inhibition of aconitine-induced arrhythmias by KBR, not by SEA, might result from a mechanism other than the inhibition of NCX, and thus the involvement of the NCX system plays an insignificant role in the aconitine-induced arrhythmias.

Postnatal outcome of fetal bradycardia without significant cardiac abnormalities

BACKGROUND

A heart rate <100 beats/min may be present in 5% of fetuses with arrhythmia. In this study, we sought to define the feasibility of in utero diagnosis of the underlying mechanisms and the postnatal outcome.

METHODS

The types of fetal bradycardia were defined by fetal echocardiogram. Fetuses with transient sinus bradycardia were excluded.

RESULTS

From 1995-2000, a total of 18 fetuses were found to have bradycardia. Postnatal 12-lead electrocardiograms made at least 3 times during follow-up confirmed the cardiac rhythm in all except those terminated during pregnancy. Sick sinus bradycardia was noted in 4 patients (22 %), of whom 1 had a positive family history and 2 received permanent pacemakers at age 4 and 5 years. Frequent nonconducted atrial premature beats or nonconducted atrial bigeminy or trigeminy were noted in 5 (28%). All of them revealed normal sinus rhythm after birth. Atrioventricular (AV) block was noted in 6 (33%), of whom 3 were terminated due to severe heart failure, and another 2 fetuses received permanent pacemaker implantation soon after birth. Only 1 fetus whose mother showed normal levels of C3 and C4 recovered at late gestation. Most importantly, 3 patients (17%) developed intermittent bradycardia (AV block) and ventricular tachycardia during the fetal stage. They were found to have long QT syndrome. Two of them died during early infancy. One received in utero propranolol and postnatal propranolol and nicorandil with satisfactory control.

CONCLUSION

The mechanisms responsible for fetal bradycardia were diverse and could be characterized by fetal echocardiography. The prognosis was poor in those with long QT syndrome manifested as intermittent fetal bradycardia and tachycardia with AV dissociation.