Sudden coronary death: pharmacological interventions for the prevention of ventricular fibrillation

Cardiac cell volume: crystal clear or murky waters? A comparison with other cell types

The osmolarity of bodily fluids is strictly controlled so that most cells do not experience changes in osmotic pressure under normal conditions, but osmotic changes can occur in pathological states such as ischemia, septic shock, and diabetic coma. The primary effect of a change in osmolarity is to acutely alter cell volume. If the osmolarity around a cell is decreased, the cell swells, and if increased, it shrinks. In order to tolerate changes in osmolarity, cells have evolved volume regulatory mechanisms activated by osmotic challenge to normalise cell volume and maintain normal function. In the heart, osmotic stress is encountered during a period of myocardial ischemia when metabolites such as lactate accumulate intracellularly and to a certain degree extracellularly, and cause cell swelling. This swelling may be exacerbated further on reperfusion when the hyperosmotic extracellular milieu is replaced by normosmotic blood. In this review, we describe the theory and mechanisms of volume regulation, and draw on findings in extracardiac tissues, such as kidney, whose responses to osmotic change are well characterised. We then describe cell volume regulation in the heart, with particular emphasis on the effect of myocardial ischemia. Finally, we describe the consequences of osmotic cell swelling for the cell and for the heart, and discuss the implications for antiarrhythmic drug efficacy. Using computer modelling, we have summated the changes induced by cell swelling, and predict that swelling will shorten the action potential. This finding indicates that cell swelling is an important component of the response to ischemia, a component modulating the excitability of the heart.

Which cardiac potassium channel subtype is the preferable target for suppression of ventricular arrhythmias?

Prolongation of the cardiac action potential duration is the hallmark of Class III antiarrhythmic activity. Action potential duration prolongation may be achieved by several means: enhancement of inward current and, more commonly, blockade of one or more of the many outward currents that are carried by K+. However, it is far from clear whether blockade of one particular K+ channel is more efficacious than blockade of another. The objective of this review is to consider this question with particular reference to ischaemic heart disease, a condition for which effective prevention of ventricular arrhythmias continues to be sought.

An in vitro method for the evaluation of antiarrhythmic and antiischemic agents by using programmed electrical stimulation of rabbit heart

A new model using isolated rabbit hearts perfused at constant flow in the Langendorff mode with the sinus node destroyed and under constant (2 Hz) pacing is described. Ventricular ischemia (24 min) was induced by ligation of the left ventricular branch of the coronary artery (LVB), followed by reperfusion (15 min). The programmed electrical stimulation (PES) technique was used to induce arrhythmias in the ischemic zone (IZ). Three agents with different mechanisms of action were tested to validate this model: dl-sotalol (10(-6) and 10(-5) M), oxfenicine (10(-6) M), and lidocaine (10(-5) M). These compounds were administered 15 min before the ligature and maintained until the end of the experiment. Ventricular effective refractory period (VERP), PES-induced ventricular fibrillation (VF), and coronary perfusion pressure (CPP) were monitored. PES-induced VF was only observed in ischemic tissue. Sotalol slightly reduced VF incidence only during reperfusion. Oxfenicine prevented PES-induced VF during the ischemia, but not during reperfusion, while lidocaine prevented VF during ischemia and throughout the reperfusion period. In conclusion, the rabbit heart model where PES is applied to normal and ischemic myocardium, appears useful to discern different mechanisms involved in ventricular arrhythmias. In addition, this model is considerably cheaper than equivalent dog models.

Selective IK blockade as an antiarrhythmic mechanism: effects of UK66,914 on ischaemia and reperfusion arrhythmias in rat and rabbit hearts

1. UK66,914 is a specific and selective blocker of the delayed rectifying potassium current (IK). The effectiveness of IK block as a mechanism for prevention of ischaemia- and reperfusion-induced arrhythmias was tested by use of UK66,914: its actions in rat, a species deficient in cardiac IK were compared with its actions in rabbit, a species possessing functional cardiac IK. Antiarrhythmic actions in rabbit but none in rat is the only outcome possible if selective IK blockade is responsible for the antiarrhythmic actions of the drug during ischaemia and/or reperfusion. 2. During 30 min regional ischaemia, 0.3 and 1 microM UK66,914 had no influence on the incidence of ventricular fibrillation (VF) in rat (n = 9/group), values being 78% in controls, 100% in 0.3 microM-treated hearts and 78% in 1.0 microM-treated hearts (NS). UK66,914 also had no effect on reperfusion-induced VF incidence (100% in each group), nor on the latency to onset of ischaemia- or reperfusion-induced arrhythmias. In contrast, in rabbit (n = 13/group), similar concentrations of drug reduced the incidence of reperfusion-induced VF from 77% in controls, to 38% and 31% (P < 0.05) respectively. The incidence of ischaemia-induced arrhythmias was too low in controls to permit detection of an antiarrhythmic effect in rabbit; however no drug-induced proarrhythmia was seen.(ABSTRACT TRUNCATED AT 250 WORDS)

Sudden death and experimental acute myocardial infarction

Acute myocardial ischemia was produced by ligature of the anterior descending coronary artery on 658 dogs in 3 separate laboratories. Overall, 12% of the dogs died within the first hour (instantaneous death) and 25% within the first 24 hours (sudden death). The sudden death rate was significantly related to the logarithm of the weight of the dogs in the range studied. It varied widely if values from small series, comprising the same number of dogs, were considered. Values became less dispersed as the size of the series increased. In series of 10 dogs, sudden death rates ranged from 0 to 70%, whereas in series of 100 dogs the range was 14 to 36%. Stable values were obtained for 50 to 60 dogs per series. Accordingly, reliable assessment of preventive measures can be made only with experimental series of at least this size.