Ventricular defibrillating properties of catecholamine uptake inhibitors

Electrocardiographic findings associated with cocaine use in humans: a systematic review

Cocaine remains highly prevalent and accessible in the general population, continues to represent one of the most commonly reported substances in drug-related presentations to emergency departments, and is frequently implicated in drug-related deaths. Fatal cardiac arrhythmias are often suspected in the latter cases. In spite of this, its complex effects on the human cardiac conduction system remain poorly elucidated. In this article we sought to systematically review the medical literature to identify the electrocardiographic findings that have been linked to cocaine use in humans in an effort to highlight what physicians can expect to encounter when managing patients using the drug. The evidence is discussed, common findings are emphasized and clinical recommendations are proposed.

A new class of antiarrhythmic-defibrillatory agents

Novel dibenzoazepine and 11-oxo-dibenzodiazepine derivatives are shown to be effective ventricular defibrillating drug candidates. They exhibit significant in vivo defibrillatory activity with no observed changes in ECG either before or after the VF event. These compounds also exhibit antifibrillatory activity by elevating the fibrillation threshold potential, all suggesting that such drugs could be used to treat VF either by themselves or together with electrical defibrillators.

Are the antiarrhythmic-defibrillating effects of D-sotalol due to or despite the prolongation of the action potential duration?

These results support our hypothesis that class III compounds, with a positive inotropic effect, increase intercellular coupling and synchronization, mainly by preventing intracellular Ca overload. They act as defibrillating compound, similar to cAMP and adrenaline, most probably due to their so called sympathomimetic effect. In our opinion, their cardioprotective effects, resembling cardioversion, are not related to their ability to prolong APD and ERP. Moreover, we suggest that any compound that possesses these sympathomimetic effects, but without inducing the arrhythmogenic prolongation of APD, may exhibit a potent, safety and more efficient antiarrhythmic - defibrillating ability.

Limb ischemia preconditions the heart against reperfusion tachyarrhythmia

We investigated the hypothesis that a cardioprotective, antiarrhythmic effect might be obtained by brief ischemia of a remote part of the body before ischemia of the heart. Regional ischemia (RI) was induced in isolated Langendorff-perfused rat hearts: group I, 30-min RI and reperfusion (control hearts; n = 18); group II, 5-min RI before 30-min RI (a reference group of "classic" ischemic preconditioning; n = 12); and group III, ischemic preconditioning with in vivo 10-min limb ischemia (LI) before 30-min RI in the perfused heart (n = 20). A significant decrease in reperfusion arrhythmia was found in groups II and III compared with group I (P < 0.02). Release of norepinephrine (NE) and prostacyclin was higher in hearts from animals pretreated with LI (P < 0.05). Prostacyclin increased in all groups at minute 1 of reperfusion, but there was no correlation to the antiarrhythmic effect. NE increased at the beginning of reperfusion after 30 min of ischemia; this release was significantly diminished after preconditioning with LI (P < 0.05). We further investigated the role of NE in preconditioning with LI using drug interventions. Pretreatment with exogenous NE protected against tachyarrhythmia. Reserpine given 24 h before LI partially abolished the antiarrhythmic effect of LI preconditioning. However, the alpha1-adrenoreceptor blocker prazosin did not prevent the effect of LI preconditioning on either ischemic or reperfusion tachyarrhythmia. Therefore, brief ischemia of an extremity protects against reperfusion tachyarrhythmia. One of the humoral mediators involved in this response appears to be NE; others remain to be identified.

Sotalol facilitates spontaneous ventricular defibrillation by enhancing intercellular coupling. An entirely new mechanism for its antiarrhythmic action

We have previously shown that sotalol, a class III antiarrhythmic agent, helps spontaneous ventricular defibrillation in various mammalian species. Since we hypothesized that self ventricular defibrillation depends on a high degree of intercellular synchronization, and since the major electrophysiological action of sotalol causing prolongation of action potential duration (APD), cannot fully explain its defibrillating property, we carried out a series of studies to examine the effect of sotalol on intercellular myocardial coupling. Guinea pig right ventricular muscle preparations were superfused in a tissue bath and the spread of intracellularly injected fluorescent dye (Lucifer yellow CH) to the neighboring cells was studied under various conditions. When either the Ca2+ concentration of Tyrode's solution was elevated to 6 mM or the solution was made hypoxic by not bubbling O2 (n = 3 each), no spread of the injected dye was observed. The addition of 1 microM sotalol to the high Ca2+ solution or 0.5 microM to the hypoxic superfusate (n = 3 each) caused a wide spreading of the dye, thus strongly suggesting a marked improvement in the intercellular coupling. These results show an entirely new property of sotalol, i.e., enhancement of cellular synchronization, which may better explain its ability to cause spontaneous ventricular defibrillation than its class III action. Our previous demonstration of successful spontaneous ventricular defibrillation by several other agents that are known to enhance intercellular coupling but have contrasting actions on APD further substantiates our hypothesis.

How can we facilitate spontaneous termination of ventricular fibrillation and prevent sudden cardiac death? A working hypothesis

Ventricular fibrillation (VF) is one of the most life-threatening arrhythmias encountered in daily clinical practice. Its occurrence cannot be completely prevented by currently used antiarrhythmic drugs, and, in most instances, VF is sustained and leads to the patient's death unless a successful DC defibrillation is applied. However, spontaneous reversion of VF to sinus rhythm has been observed in various animals and occasionally even in man. Hence, facilitation of self-ventricular defibrillation must be explored as an alternative therapeutic approach. In experimental studies using several mammalian species, we have found that self ventricular defibrillation requires a good intercellular coupling and well synchronized electrical activity in the ventricles, which, in untreated animals, depend on their myocardial catecholamine content. It can then be hypothesized that any agent that elevates the catecholamine level during VF would facilitate spontaneous ventricular defibrillation, and drugs inhibiting extraneuronal catecholamine reuptake have indeed been shown to possess this ability. It is suggested that their effects are mediated by an increase in the intracellular cAMP level, and any compounds sharing this property could well prove efficacious in making VF transient and in reducing sudden cardiac death.

The role of catecholamines on intercellular coupling, myocardial cell synchronization and self ventricular defibrillation

Ventricular fibrillation (VF) is one of the most life threatening events. Although in humans VF is generally sustained (SVF) requiring artificial defibrillation, in various mammals and in some cases in humans VF terminates by itself, reverting spontaneously into sinus rhythm. Since VF is one of the main causes of sudden death, one of the important clinical problems today is if and how we can transform the fatal SVF into a self limited transient one (TVF). From electrophysiological studies carried out on anaesthetized open chest animals, we have found that TVF requires a high degree of intercellular coupling and synchronization. Cardiac myocytes are electrically coupled with adjacent cells. The intercellular coupling is a focus of low electrical resistance which allows rapid transmission of electrical impulses between cells. Any decrease in intercellular coupling decreases the ability of the heart for self defibrillation. The cell-to-cell coupling decreases with age, ischemia, VF and variations in physiological conditions probably due to an increase in intercellular resistance (Ri), widening in the internexal gaps, decrease in electrotonic space constant (lambda) etc. All of these factors are known to be affected by intracellular concentration of free Ca++ ([Ca++]). On the basis of studies carried out on various mammals at different ages, we hypothesized that the ability of the heart to defibrillate depends on the cardiac catecholamine level [CA], during VF. This hypothesis is supported by the facts, known from the literature, that increase in [CA] decreases intracellular free Ca++ concentration, decreases Ri and increases lambda.(ABSTRACT TRUNCATED AT 250 WORDS)

The defibrillating effect of catecholamine reuptake inhibitors

In previous studies we hypothesized that spontaneous termination of ventricular fibrillation (TVF) requires a high cardiac catecholamine level ([CA]) during VF. During VF, sympathetic activity is enhanced but in the majority of cases [CA] does not reach the level required for self-defibrillation, most likely due to their relatively high reuptake by sympathetic nerve terminals. One possibility of obtaining TVF is by elevation of the [CA] during VF, either by catecholamine intracoronary injection or by treatment with compounds that inhibit catecholamine reuptake. To examine this assumption, we studied the effect of VF on 3 closely related compounds: talopram, talsupram and citalopram, with norepinephrine uptake inhibition (IC50NE) of 2.9, 0.79 and 8800 and dopamine (DA) uptake inhibition (IC50DA) of 44000, 9300 and 41000, respectively, as well as 2 enantiomers of a cis-1-piperazino-3-phenylindan derivative (Lu20-037 and Lu20-036) with IC50NE of 2.5 and 910 and IC50DA of 2.3 and 1700, respectively. The results support our hypothesis relating the defibrillating effect of a compound to its IC50NE, while its inhibitory effect on DA uptake seems to conteract the NE effect.

A self-protecting servo-model for explanation of the mechanism involved in spontaneous ventricular defibrillation

Ventricular fibrillation (VF) is the most life-threatening arrhythmia. It has been suggested that VF in humans is always sustained. Recent publications indicated that VF can be either sustained (SVF) or transient (TVF), reverting spontaneously into sinus rhythm. In previous studies we have hypothesized that TVF requires, during VF, a high cardiac catecholamine level ([CA]). Since during VF sympathetic activity is enhanced, the question arises of why VF is sustained in the majority of cases. Looking on the living body as a self-protecting servo-mechanism, we propose a servo-model that on the one hand describes the mechanism involved in TVF and on the other proposes a therapeutic procedure which can help the heart in its effort to transform VF into TVF. Our model has been examined by various experimental studies. The results obtained strongly support our hypothesis.

Ethmozine and ethacizine--new antiarrhythmic drugs with defibrillating properties

Ventricular fibrillation (VF) is a life-threatening arrhythmia that leads to death unless electrical defibrillation is applied in time. Recent publications indicate that VF can be either sustained (SVF), requiring electrical defibrillation, or transient (TVF), reverting spontaneously into sinus rhythm. Since VF cannot be totally prevented by drugs, a new antiarrhythmic therapeutic approach has been proposed: drug-induced enhancement of the ability of the heart to defibrillate by itself. In this study we examined the defibrillating potency of two antiarrhythmic phenothiazines, ethmozine (ETM) and ethacizine (ETA), as well as their effects on catecholamine uptake and on the electrophysiological properties of the myocardial cell membrane. The antiarrhythmic-defibrillatory activity was examined in cats; the inhibitory effect on [3H]-norepinephrine (NE) uptake was examined in rat brain synaptosomes, and the electrophysiological membrane effects were examined by microelectrode recordings in perfused strips of heart ventricle from guinea-pigs. The results indicate that: 1. ETA exhibits similar but stronger antiarrhythmic-defibrillating and NE reuptake inhibitory effects than ETM; 2. ETA at 10-6 M decreases ventricular conduction time and increases Vmax while ETM at this concentration does not change them; 3. The defibrillating ability of the drugs can be related to their inhibitory potency on NE reuptake. We suggest that the risk of sympathomimetic arrhythmogenicity is prevented by the previously described, membrane stabilizing Class 1 antiarrhythmic properties of these drugs.