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Corponi F, Fabbri C, Boriani G, Diemberger I, Albani D, Forloni G, Serretti A. Corrected QT Interval Prolongation in Psychopharmacological Treatment and Its Modulation by Genetic Variation. Neuropsychobiology 2019; 77:67-72. [PMID: 30544110 DOI: 10.1159/000493400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/29/2018] [Indexed: 11/19/2022]
Abstract
Several antipsychotics and antidepressants have been associated with electrocardiogram alterations, the most clinically relevant of which is the heart rate-corrected QT interval (QTc) prolongation, a risk factor for sudden cardiac death. Genetic variants influence drug-induced QTc prolongation and can provide valuable information for precision medicine. The effect of genetic variants on QTc prolongation as well as the possible interaction between polymorphisms and risk medications in determining QTc prolongation were investigated. Medications were classified according to their known risk of inducing QTc prolongation (high-to-moderate, low, and no risk). QTc duration and risk of QTc > median value were investigated in a sample of 77 patients with mood or psychotic disorders being treated with antidepressants and antipsychotics, and who had at least 1 ECG recording. A secondary analysis considered QTc percentage change in patients (n = 25) with 2 ECG recordings. Single-nucleotide polymorphisms previously associated with QTc prolongation during treatment with psychotropic medications were investigated. No association survived after multiple-testing correction. The best results for modulation of QTc duration were identified for rs10808071 (the ABCB1 gene, nominal p = 0.007) when at least 1 medication with a moderate-to-high risk was prescribed, and for rs12029454 (the NOS1AP gene) in patients taking at least 1 medication with a cardiovascular risk (nominal p = 0.008). In the secondary analysis, rs2072413 (the KCNH2 gene) was the top finding for the modulation of QTc percentage change (nominal p = 0.001) when 1 drug with a moderate-to-high risk was added compared to baseline. Despite the limited power of this study, our results suggest that ABCB1, NOS1AP, and KCNH2 may play a role in QTc duration/prolongation during treatment with psychotropic drugs.
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Affiliation(s)
- Filippo Corponi
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Chiara Fabbri
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Igor Diemberger
- Department of Specialist, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
| | - Diego Albani
- Unità Genetica delle Malattie Neurodegenerative, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Gianluigi Forloni
- Unità Genetica delle Malattie Neurodegenerative, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Alessandro Serretti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy,
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Zerdazi EH, Vorspan F, Marees AT, Naccache F, Lepine JP, Laplanche JL, Prince N, Marie-Claire C, Bellivier F, Mouly S, Bloch V. QT length during methadone maintenance treatment: gene × dose interaction. Fundam Clin Pharmacol 2019; 33:96-106. [DOI: 10.1111/fcp.12405] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/04/2018] [Accepted: 08/01/2018] [Indexed: 12/11/2022]
Affiliation(s)
- El-Hadi Zerdazi
- INSERM U1144 Variabilité de réponse aux psychotropes; Université Paris Descartes; Université Paris Diderot; Université Sorbonne Paris Cité; Faculté de Pharmacie; 4 avenue de l'observatoire - 75006 Paris France
- APHP; Service d'addictologie; DHU Pe-PSY; Pôle de Psychiatrie et d'Addictologie des Hôpitaux Universitaires; Henri Mondor; F94000 Créteil France
| | - Florence Vorspan
- INSERM U1144 Variabilité de réponse aux psychotropes; Université Paris Descartes; Université Paris Diderot; Université Sorbonne Paris Cité; Faculté de Pharmacie; 4 avenue de l'observatoire - 75006 Paris France
- APHP; Département de Psychiatrie et de Médecine Addictologigue; Hôpital Fernand Widal; 75010 Paris France
| | - Andries T. Marees
- Department of Psychiatry, Amsterdam Neuroscience; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
- QIMR Berghofer; Translational Neurogenomics Group; Brisbane Australia
| | - François Naccache
- INSERM U1144 Variabilité de réponse aux psychotropes; Université Paris Descartes; Université Paris Diderot; Université Sorbonne Paris Cité; Faculté de Pharmacie; 4 avenue de l'observatoire - 75006 Paris France
- APHP; Département de Psychiatrie et de Médecine Addictologigue; Hôpital Fernand Widal; 75010 Paris France
| | - Jean-Pierre Lepine
- INSERM U1144 Variabilité de réponse aux psychotropes; Université Paris Descartes; Université Paris Diderot; Université Sorbonne Paris Cité; Faculté de Pharmacie; 4 avenue de l'observatoire - 75006 Paris France
- APHP; Département de Psychiatrie et de Médecine Addictologigue; Hôpital Fernand Widal; 75010 Paris France
| | - Jean-Louis Laplanche
- INSERM U1144 Variabilité de réponse aux psychotropes; Université Paris Descartes; Université Paris Diderot; Université Sorbonne Paris Cité; Faculté de Pharmacie; 4 avenue de l'observatoire - 75006 Paris France
| | - Nathalie Prince
- INSERM U1144 Variabilité de réponse aux psychotropes; Université Paris Descartes; Université Paris Diderot; Université Sorbonne Paris Cité; Faculté de Pharmacie; 4 avenue de l'observatoire - 75006 Paris France
| | - Cynthia Marie-Claire
- INSERM U1144 Variabilité de réponse aux psychotropes; Université Paris Descartes; Université Paris Diderot; Université Sorbonne Paris Cité; Faculté de Pharmacie; 4 avenue de l'observatoire - 75006 Paris France
| | - Frank Bellivier
- INSERM U1144 Variabilité de réponse aux psychotropes; Université Paris Descartes; Université Paris Diderot; Université Sorbonne Paris Cité; Faculté de Pharmacie; 4 avenue de l'observatoire - 75006 Paris France
- APHP; Département de Psychiatrie et de Médecine Addictologigue; Hôpital Fernand Widal; 75010 Paris France
- Fondation FondaMental; Fondation de coopération scientifique; Hôpital Albert Chenevier; 94000 Créteil France
| | - Stéphane Mouly
- INSERM U1144 Variabilité de réponse aux psychotropes; Université Paris Descartes; Université Paris Diderot; Université Sorbonne Paris Cité; Faculté de Pharmacie; 4 avenue de l'observatoire - 75006 Paris France
- Département de Médecine Interne; Hôpital Lariboisière; APHP; 75010 Paris France
| | - Vanessa Bloch
- INSERM U1144 Variabilité de réponse aux psychotropes; Université Paris Descartes; Université Paris Diderot; Université Sorbonne Paris Cité; Faculté de Pharmacie; 4 avenue de l'observatoire - 75006 Paris France
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Association Between Particulate Air Pollution and QT Interval Duration in an Elderly Cohort. Epidemiology 2017; 27:284-90. [PMID: 26605812 DOI: 10.1097/ede.0000000000000424] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Short-term fine particulate matter (PM2.5) exposure has been linked with increased QT interval duration, a marker of ventricular repolarization and a risk factor for cardiac arrhythmia and sudden death, in several studies. Only one previous study evaluated whether long-term PM exposure is related to the QT interval. We aim to evaluate whether subchronic and long-term exposure to PM2.5 at home is linked with QT duration in an elderly cohort. METHODS We measured heart-rate corrected QT interval duration among 404 participants from the Greater Boston area between 2003 and 2011. We modeled residential PM2.5 exposures using a hybrid satellite- and land use-based model. We evaluated associations between moving averages of short-term (1-2 days), subchronic (3-28 days), and long-term (1 year) pollutant exposures and corrected QT duration using linear mixed models. We also evaluated effect modification by oxidative stress genetic score using separated regression models and interaction terms. RESULTS We observed positive associations between subchronic and long-term PM2.5 exposure and corrected QT duration, with the strongest results for longer-term exposures. For example, a one standard deviation increase in 1-year PM2.5 was associated with a 6.3 ms increase in corrected QT (95% confidence interval: 1.8, 11). We observed somewhat greater effects among subjects with higher (8.5 ms) rather than lower (3.1 ms) oxidative stress allelic profiles (P interaction = 0.25). CONCLUSIONS PM2.5 was associated with increased corrected QT duration in an elderly cohort. While most previous studies focused on short-term air pollution exposures, our results suggest that longer-term exposures are associated with cardiac repolarization.
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Silva CT, Zorkoltseva IV, Amin N, Demirkan A, van Leeuwen EM, Kors JA, van den Berg M, Stricker BH, Uitterlinden AG, Kirichenko AV, Witteman JCM, Willemsen R, Oostra BA, Axenovich TI, van Duijn CM, Isaacs A. A Combined Linkage and Exome Sequencing Analysis for Electrocardiogram Parameters in the Erasmus Rucphen Family Study. Front Genet 2016; 7:190. [PMID: 27877193 PMCID: PMC5099142 DOI: 10.3389/fgene.2016.00190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 10/11/2016] [Indexed: 12/30/2022] Open
Abstract
Electrocardiogram (ECG) measurements play a key role in the diagnosis and prediction of cardiac arrhythmias and sudden cardiac death. ECG parameters, such as the PR, QRS, and QT intervals, are known to be heritable and genome-wide association studies of these phenotypes have been successful in identifying common variants; however, a large proportion of the genetic variability of these traits remains to be elucidated. The aim of this study was to discover loci potentially harboring rare variants utilizing variance component linkage analysis in 1547 individuals from a large family-based study, the Erasmus Rucphen Family Study (ERF). Linked regions were further explored using exome sequencing. Five suggestive linkage peaks were identified: two for QT interval (1q24, LOD = 2.63; 2q34, LOD = 2.05), one for QRS interval (1p35, LOD = 2.52) and two for PR interval (9p22, LOD = 2.20; 14q11, LOD = 2.29). Fine-mapping using exome sequence data identified a C > G missense variant (c.713C > G, p.Ser238Cys) in the FCRL2 gene associated with QT (rs74608430; P = 2.8 × 10-4, minor allele frequency = 0.019). Heritability analysis demonstrated that the SNP explained 2.42% of the trait’s genetic variability in ERF (P = 0.02). Pathway analysis suggested that the gene is involved in cytosolic Ca2+ levels (P = 3.3 × 10-3) and AMPK stimulated fatty acid oxidation in muscle (P = 4.1 × 10-3). Look-ups in bioinformatics resources showed that expression of FCRL2 is associated with ARHGAP24 and SETBP1 expression. This finding was not replicated in the Rotterdam study. Combining the bioinformatics information with the association and linkage analyses, FCRL2 emerges as a strong candidate gene for QT interval.
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Affiliation(s)
- Claudia T Silva
- Genetic Epidemiology Unit, Department of Epidemiology, Erasmus University Medical CenterRotterdam, Netherlands; Doctoral Program in Biomedical Sciences, Universidad del RosarioBogotá, Colombia; GENIUROS Group, Genetics and Genomics Research Center CIGGUR, School of Medicine and Health Sciences, Universidad del RosarioBogotá, Colombia
| | - Irina V Zorkoltseva
- Institute of Cytology and Genetics, Siberian Branch of Russian Academy of Sciences Novosibirsk, Russia
| | - Najaf Amin
- Genetic Epidemiology Unit, Department of Epidemiology, Erasmus University Medical Center Rotterdam, Netherlands
| | - Ayşe Demirkan
- Genetic Epidemiology Unit, Department of Epidemiology, Erasmus University Medical CenterRotterdam, Netherlands; Department of Human Genetics, Leiden University Medical CenterLeiden, Netherlands
| | - Elisabeth M van Leeuwen
- Genetic Epidemiology Unit, Department of Epidemiology, Erasmus University Medical Center Rotterdam, Netherlands
| | - Jan A Kors
- Department of Medical Informatics, Erasmus University Medical Center Rotterdam, Netherlands
| | - Marten van den Berg
- Department of Medical Informatics, Erasmus University Medical Center Rotterdam, Netherlands
| | - Bruno H Stricker
- Department of Epidemiology, Erasmus University Medical CenterRotterdam, Netherlands; Department of Internal Medicine, Erasmus University Medical CenterRotterdam, Netherlands; Inspectorate of Health CareThe Hague, Netherlands
| | - André G Uitterlinden
- Department of Internal Medicine, Erasmus University Medical Center Rotterdam, Netherlands
| | - Anatoly V Kirichenko
- Institute of Cytology and Genetics, Siberian Branch of Russian Academy of Sciences Novosibirsk, Russia
| | | | - Rob Willemsen
- Department of Clinical Genetics, Erasmus University Medical Center Rotterdam, Netherlands
| | - Ben A Oostra
- Genetic Epidemiology Unit, Department of Epidemiology, Erasmus University Medical CenterRotterdam, Netherlands; Center for Medical Systems BiologyLeiden, Netherlands
| | - Tatiana I Axenovich
- Institute of Cytology and Genetics, Siberian Branch of Russian Academy of Sciences Novosibirsk, Russia
| | - Cornelia M van Duijn
- Genetic Epidemiology Unit, Department of Epidemiology, Erasmus University Medical CenterRotterdam, Netherlands; Center for Medical Systems BiologyLeiden, Netherlands
| | - Aaron Isaacs
- Genetic Epidemiology Unit, Department of Epidemiology, Erasmus University Medical CenterRotterdam, Netherlands; Center for Medical Systems BiologyLeiden, Netherlands
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Interleukin-1β gene variants are associated with QTc interval prolongation following cardiac surgery: a prospective observational study. Can J Anaesth 2016; 63:397-410. [PMID: 26858093 DOI: 10.1007/s12630-015-0576-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 10/13/2015] [Accepted: 12/21/2015] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND We characterized cardiac surgery-induced dynamic changes of the corrected QT (QTc) interval and tested the hypothesis that genetic factors are associated with perioperative QTc prolongation independent of clinical and procedural factors. METHODS All study subjects were ascertained from a prospective study of patients who underwent elective cardiac surgery during August 1999 to April 2002. We defined a prolonged QTc interval as > 440 msec, measured from 24-hr pre- and postoperative 12-lead electrocardiograms. The association of 37 single nucleotide polymorphisms (SNPs) in 21 candidate genes -involved in modulating arrhythmia susceptibility pathways with postoperative QTc changes- was investigated in a two-stage design with a stage I cohort (n = 497) nested within a stage II cohort (n = 957). Empirical P values (Pemp) were obtained by permutation tests with 10,000 repeats. RESULTS After adjusting for clinical and procedural risk factors, we selected four SNPs (P value range, 0.03-0.1) in stage I, which we then tested in the stage II cohort. Two functional SNPs in the pro-inflammatory cytokine interleukin-1β (IL1β), rs1143633 (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.53 to 0.95; Pemp = 0.02) and rs16944 (OR, 1.31; 95% CI, 1.01 to 1.70; Pemp = 0.04), remained independent predictors of postoperative QTc prolongation. The ability of a clinico-genetic model incorporating the two IL1B polymorphisms to classify patients at risk for developing prolonged postoperative QTc was superior to a clinical model alone, with a net reclassification improvement of 0.308 (P = 0.0003) and an integrated discrimination improvement of 0.02 (P = 0.000024). CONCLUSION The results suggest a contribution of IL1β in modulating susceptibility to postoperative QTc prolongation after cardiac surgery.
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Petropoulou E, Jamshidi Y, Behr ER. The genetics of pro-arrhythmic adverse drug reactions. Br J Clin Pharmacol 2014; 77:618-25. [PMID: 23834499 DOI: 10.1111/bcp.12208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 06/26/2013] [Indexed: 12/19/2022] Open
Abstract
Ventricular arrhythmia induced by drugs (pro-arrythmia) is an uncommon event, whose occurrence is unpredictable but potentially fatal. The ability of a variety of medications to induce these arrhythmias is a significant problem facing the pharmaceutical industry. Genetic variants have been shown to play a role in adverse events and are also known to influence an individual's optimal drug dose. This review provides an overview of the current understanding of the role of genetic variants in modulating the risk of drug induced arrhythmias.
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Affiliation(s)
- Evmorfia Petropoulou
- Human Genetics Research Centre, Division of Biomedical Sciences, St George's Hospital Medical School, London, SW17 0RE, UK
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Roder K, Werdich AA, Li W, Liu M, Kim TY, Organ-Darling LE, Moshal KS, Hwang JM, Lu Y, Choi BR, MacRae CA, Koren G. RING finger protein RNF207, a novel regulator of cardiac excitation. J Biol Chem 2014; 289:33730-40. [PMID: 25281747 DOI: 10.1074/jbc.m114.592295] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Two recent studies (Newton-Cheh, C. et al. (2009) Common variants at ten loci influence QT interval duration in the QTGEN Study. Nat. Genet. 41, 399-406 and Pfeufer, A. et al. (2009) Common variants at ten loci modulate the QT interval duration in the QTSCD Study. Nat. Genet. 41, 407-414) identified an association, with genome-wide significance, between a single nucleotide polymorphism within the gene encoding RING finger protein 207 (RNF207) and the QT interval. We sought to determine the role of RNF207 in cardiac electrophysiology. Morpholino knockdown of RNF207 in zebrafish embryos resulted in action potential duration prolongation, occasionally a 2:1 atrioventricular block, and slowing of conduction velocity. Conversely, neonatal rabbit cardiomyocytes infected with RNF207-expressing adenovirus exhibited shortened action potential duration. Using transfections of U-2 OS and HEK293 cells, Western blot analysis and immunocytochemistry data demonstrate that RNF207 and the human ether-a-go-go-related gene (HERG) potassium channel interact and colocalize. Furthermore, RNF207 overexpression significantly elevated total and membrane HERG protein and HERG-encoded current density by ∼30-50%, which was dependent on the intact N-terminal RING domain of RNF207. Finally, coexpression of RNF207 and HSP70 increased HERG expression compared with HSP70 alone. This effect was dependent on the C terminus of RNF207. Taken together, the evidence is strong that RNF207 is an important regulator of action potential duration, likely via effects on HERG trafficking and localization in a heat shock protein-dependent manner.
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Affiliation(s)
- Karim Roder
- From the Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island 02903
| | - Andreas A Werdich
- the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, and
| | - Weiyan Li
- From the Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island 02903
| | - Man Liu
- From the Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island 02903
| | - Tae Yun Kim
- From the Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island 02903
| | - Louise E Organ-Darling
- the Department of Biological Sciences, Wellesley College, Wellesley, Massachusetts 02481
| | - Karni S Moshal
- From the Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island 02903
| | - Jung Min Hwang
- From the Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island 02903
| | - Yichun Lu
- From the Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island 02903
| | - Bum-Rak Choi
- From the Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island 02903
| | - Calum A MacRae
- the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, and
| | - Gideon Koren
- From the Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island 02903,
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van Duijvenboden K, Ruijter JM, Christoffels VM. Gene regulatory elements of the cardiac conduction system. Brief Funct Genomics 2013; 13:28-38. [PMID: 23969024 DOI: 10.1093/bfgp/elt031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The coordinated contraction of the heart relies on the generation and conduction of the electrical impulse. Aberrations of the function of the cardiac conduction system have been associated with various arrhythmogenic disorders and increased risk of sudden cardiac death. The genetics underlying conduction system function have been investigated using functional studies and genome-wide association studies. Both methods point towards the involvement of ion channel genes and the transcription factors that govern their activity. A large fraction of disease- and trait-associated sequence variants lie within non-coding sequences, enriched with epigenetic marks indicative of regulatory DNA. Although sequence conservation as a result of functional constraint has been a useful property to identify transcriptional enhancers, this identification process has been advanced through the development of techniques such as ChIP-seq and chromatin conformation capture technologies. The role of variation in gene regulatory elements in the cardiac conduction system has recently been demonstrated by studies on enhancers of SCN5A/SCN10A and TBX5. In both studies, a region harbouring a functionally implicated single-nucleotide polymorphism was shown to drive reproducible cardiac expression in a reporter gene assay. Furthermore, the risk variant of the allele abrogated enhancer function in both cases. Functional studies on regulatory DNA will likely receive a boost through recent developments in genome modification technologies.
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Affiliation(s)
- Karel van Duijvenboden
- Department of Anatomy, Embryology & Physiology, Academic Medical Centre, L2-108, Meibergdreef 15, 1105 AZ Amsterdam, the Netherlands. Tel.: + 31 20 5667821; Fax: + 31 20 6976177;
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Mahida S, Hogarth AJ, Cowan C, Tayebjee MH, Graham LN, Pepper CB. Genetics of congenital and drug-induced long QT syndromes: current evidence and future research perspectives. J Interv Card Electrophysiol 2013; 37:9-19. [PMID: 23515882 DOI: 10.1007/s10840-013-9779-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 01/07/2013] [Indexed: 12/17/2022]
Abstract
The long QT syndrome (LQTS) is a condition characterized by abnormal prolongation of the QT interval with an associated risk of ventricular arrhythmias and sudden cardiac death. Congenital forms of LQTS arise due to rare and highly penetrant mutations that segregate in a Mendelian fashion. Over the years, multiple mutations in genes encoding ion channels and ion channel binding proteins have been reported to underlie congenital LQTS. Drugs are by far the most common cause of acquired forms of LQTS. Emerging evidence suggests that drug-induced LQTS also has a significant heritable component. However, the genetic substrate underlying drug-induced LQTS is presently largely unknown. In recent years, advances in next-generation sequencing technology and molecular biology techniques have significantly enhanced our ability to identify genetic variants underlying both monogenic diseases and more complex traits. In this review, we discuss the genetic basis of congenital and drug-induced LQTS and focus on future avenues of research in the field. Ultimately, a detailed characterization of the genetic substrate underlying congenital and drug-induced LQTS will enhance risk stratification and potentially result in the development of tailored genotype-based therapies.
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Affiliation(s)
- Saagar Mahida
- Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK.
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Smith JG, Avery CL, Evans DS, Nalls MA, Meng YA, Smith EN, Palmer C, Tanaka T, Mehra R, Butler AM, Young T, Buxbaum SG, Kerr KF, Berenson GS, Schnabel RB, Li G, Ellinor PT, Magnani JW, Chen W, Bis JC, Curb JD, Hsueh WC, Rotter JI, Liu Y, Newman AB, Limacher MC, North KE, Reiner AP, Quibrera PM, Schork NJ, Singleton AB, Psaty BM, Soliman EZ, Solomon AJ, Srinivasan SR, Alonso A, Wallace R, Redline S, Zhang ZM, Post WS, Zonderman AB, Taylor HA, Murray SS, Ferrucci L, Arking DE, Evans MK, Fox ER, Sotoodehnia N, Heckbert SR, Whitsel EA, Newton-Cheh C. Impact of ancestry and common genetic variants on QT interval in African Americans. CIRCULATION. CARDIOVASCULAR GENETICS 2012; 5:647-55. [PMID: 23166209 PMCID: PMC3568265 DOI: 10.1161/circgenetics.112.962787] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ethnic differences in cardiac arrhythmia incidence have been reported, with a particularly high incidence of sudden cardiac death and low incidence of atrial fibrillation in individuals of African ancestry. We tested the hypotheses that African ancestry and common genetic variants are associated with prolonged duration of cardiac repolarization, a central pathophysiological determinant of arrhythmia, as measured by the electrocardiographic QT interval. METHODS AND RESULTS First, individual estimates of African and European ancestry were inferred from genome-wide single-nucleotide polymorphism (SNP) data in 7 population-based cohorts of African Americans (n=12,097) and regressed on measured QT interval from ECGs. Second, imputation was performed for 2.8 million SNPs, and a genome-wide association study of QT interval was performed in 10 cohorts (n=13,105). There was no evidence of association between genetic ancestry and QT interval (P=0.94). Genome-wide significant associations (P<2.5 × 10(-8)) were identified with SNPs at 2 loci, upstream of the genes NOS1AP (rs12143842, P=2 × 10(-15)) and ATP1B1 (rs1320976, P=2 × 10(-10)). The most significant SNP in NOS1AP was the same as the strongest SNP previously associated with QT interval in individuals of European ancestry. Low probability values (P<10(-5)) were observed for SNPs at several other loci previously identified in genome-wide association studies in individuals of European ancestry, including KCNQ1, KCNH2, LITAF, and PLN. CONCLUSIONS We observed no difference in duration of cardiac repolarization with global genetic indices of African American ancestry. In addition, our genome-wide association study extends the association of polymorphisms at several loci associated with repolarization in individuals of European ancestry to include individuals of African ancestry.
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Affiliation(s)
- J Gustav Smith
- Department of Cardiology, Lund University, Skåne University Hospital, Sweden.
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Affiliation(s)
- Bina Joe
- Center for Hypertension and Personalized Medicine, University of Toledo College of Medicine and Life Sciences Toledo, OH (B.J., J.I.S.) ; Department of Physiology/Pharmacology, University of Toledo College of Medicine and Life Sciences Toledo, OH (B.J., J.I.S.)
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Jeff JM, Brown-Gentry K, Buxbaum SG, Sarpong DF, Taylor HA, George AL, Roden DM, Crawford DC. SCN5A variation is associated with electrocardiographic traits in the Jackson Heart Study. CIRCULATION. CARDIOVASCULAR GENETICS 2011; 4:139-44. [PMID: 21325150 PMCID: PMC3080430 DOI: 10.1161/circgenetics.110.958124] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Understanding variation in the normal electric activity of the heart, assessed by the ECG, may provide a starting point for studies of susceptibility to serious arrhythmias such as sudden cardiac death during myocardial infarction or drug therapy. Recent genetic association studies of one ECG trait, the QT interval, have identified common variation in European-descent populations, but little is known about the genetic determinants of ECG traits in populations of African descent. METHODS AND RESULTS To identify genetic risk factors, we have undertaken a candidate gene study of ECG traits in collaboration with the Jackson Heart Study, a longitudinal study of 5301 blacks ascertained from the Jackson, Mississippi, area. Nine quantitative ECG traits were evaluated: P, PR, QRS, QT, and QTc durations, heart rate, and P, QRS, and T axes. We genotyped 72 variations in the predominant sodium channel gene expressed in heart, SCN5A, encoding the Na(v)1.5 voltage-gated sodium channel in 4558 subjects. Both rare and common variants in this gene have previously been associated with inherited arrhythmia syndromes and variable conduction. Adjusting for age, sex, and European ancestry, we performed tests of association in 3054 unrelated participants and identified 14 significant associations (P<1.0×10(-4)), of which 13 are independent, based on linkage disequilibrium. These variants explain up to 2% of the variation in ECG traits in the Jackson Heart Study. CONCLUSIONS These results suggest that SCN5A variation contributes to ECG trait distributions in blacks, and these same variations may be risk or protective factors associated with susceptibility to arrhythmias.
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Affiliation(s)
- Janina M. Jeff
- Center for Human Genetics Research, Vanderbilt University, Nashville, TN 37232
| | | | - Sarah G. Buxbaum
- Jackson Heart Study, Jackson State University, Jackson, MS 39213
| | | | - Herman A. Taylor
- Jackson Heart Study, Jackson State University, Jackson, MS 39213
| | - Alfred L. George
- Department of Medicine, Vanderbilt University, Nashville, TN 37232
- Department of Pharmacology, Vanderbilt University, Nashville, TN 37232
- Institute for Integrative Genomics, Vanderbilt University, Nashville, TN 37232
| | - Dan M. Roden
- Department of Medicine, Vanderbilt University, Nashville, TN 37232
- Department of Pharmacology, Vanderbilt University, Nashville, TN 37232
| | - Dana C. Crawford
- Center for Human Genetics Research, Vanderbilt University, Nashville, TN 37232
- Department of Molecular Physiology & Biophysics, Vanderbilt University, Nashville, TN 37232
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13
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Neale BM, Rivas MA, Voight BF, Altshuler D, Devlin B, Orho-Melander M, Kathiresan S, Purcell SM, Roeder K, Daly MJ. Testing for an unusual distribution of rare variants. PLoS Genet 2011; 7:e1001322. [PMID: 21408211 PMCID: PMC3048375 DOI: 10.1371/journal.pgen.1001322] [Citation(s) in RCA: 455] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Accepted: 01/31/2011] [Indexed: 01/31/2023] Open
Abstract
Technological advances make it possible to use high-throughput sequencing as a primary discovery tool of medical genetics, specifically for assaying rare variation. Still this approach faces the analytic challenge that the influence of very rare variants can only be evaluated effectively as a group. A further complication is that any given rare variant could have no effect, could increase risk, or could be protective. We propose here the C-alpha test statistic as a novel approach for testing for the presence of this mixture of effects across a set of rare variants. Unlike existing burden tests, C-alpha, by testing the variance rather than the mean, maintains consistent power when the target set contains both risk and protective variants. Through simulations and analysis of case/control data, we demonstrate good power relative to existing methods that assess the burden of rare variants in individuals. Developments in sequencing technology now enable us to assay all genetic variation, much of which is extremely rare. We propose to test the distribution of rare variants we observe in cases versus controls. To do so, we present a novel application of the C-alpha statistic to test these rare variants. C-alpha aims to determine whether the set of variants observed in cases and controls is a mixture, such that some of the variants confer risk or protection or are phenotypically neutral. Risk variants are expected to be more common in cases; protective variants more common in controls. C-alpha is sensitive to this imbalance, regardless of its origin—risk, protective, or both—but is ideally suited for a mixture of protective and risk variants. Variation in APOB nicely illustrates a mixture, in that certain rare variants increase triglyceride levels while others decrease it. The hallmark feature of C-alpha is that it uses the distribution of variation observed in cases and controls to detect the presence of a mixture, thus implicating genes or pathways as risk factors for disease.
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Affiliation(s)
- Benjamin M. Neale
- The Center for Human Genetic Research, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- The Broad Institute of Harvard and MIT, Cambridge, Massachusetts, United States of America
- * E-mail: (BMN); (MJD); (KR)
| | - Manuel A. Rivas
- The Center for Human Genetic Research, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- The Broad Institute of Harvard and MIT, Cambridge, Massachusetts, United States of America
| | - Benjamin F. Voight
- The Center for Human Genetic Research, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- The Broad Institute of Harvard and MIT, Cambridge, Massachusetts, United States of America
| | - David Altshuler
- The Broad Institute of Harvard and MIT, Cambridge, Massachusetts, United States of America
- Department of Genetics, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Molecular Biology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Bernie Devlin
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Marju Orho-Melander
- Department of Clinical Sciences Malmö, Diabetes and Cardiovascular Diseases, Genetic Epidemiology CRC, University Hospital Malmö, Malmö, Sweden
| | - Sekar Kathiresan
- The Center for Human Genetic Research, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- The Broad Institute of Harvard and MIT, Cambridge, Massachusetts, United States of America
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Shaun M. Purcell
- The Broad Institute of Harvard and MIT, Cambridge, Massachusetts, United States of America
- Psychiatric and Neurodevelopmental Genetics Unit, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Kathryn Roeder
- Department of Statistics, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
- * E-mail: (BMN); (MJD); (KR)
| | - Mark J. Daly
- The Center for Human Genetic Research, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- The Broad Institute of Harvard and MIT, Cambridge, Massachusetts, United States of America
- * E-mail: (BMN); (MJD); (KR)
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14
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Mordukhovich I, Wright RO, Amarasiriwardena C, Baja E, Baccarelli A, Suh H, Sparrow D, Vokonas P, Schwartz J. Association between low-level environmental arsenic exposure and QT interval duration in a general population study. Am J Epidemiol 2009; 170:739-46. [PMID: 19700500 DOI: 10.1093/aje/kwp191] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
High-level arsenic exposure is consistently associated with QT prolongation, a risk factor for arrhythmia and sudden cardiac death. Arsenic may act on QT by increasing cardiac calcium currents. The authors hypothesized that low-level arsenic exposure would be associated with QT duration and that this effect would be stronger among persons not using calcium channel blockers. They performed a cross-sectional analysis in elderly men from the Normative Aging Study to analyze associations between toenail arsenic and QT and heart rate-corrected QT (QTc) durations and to examine effect modification by calcium channel blocker use, using linear regression and adjusting for potential confounders. Participants were examined in Boston, Massachusetts, between 2000 and 2002 or in 2006. An interquartile range increase in arsenic concentration was associated with a 3.8-millisecond increase in QT (95% confidence interval: 0.82, 6.8) and a 2.5-millisecond increase in QTc (95% confidence interval: 0.11, 4.9). There was no evidence of effect modification by medication use for either QT (P = 0.93) or QTc (P = 0.58). The authors observed positive associations between a biomarker of arsenic exposure and QT duration but found no evidence of effect modification by calcium channel blocker use, possibly because of modest power.
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Affiliation(s)
- Irina Mordukhovich
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina 27599-7435, USA.
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15
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Predictive value of electrocardiographic QT interval and T-wave morphology parameters for all-cause and cardiovascular mortality in a general population sample. Heart Rhythm 2009; 6:1202-8, 1208.e1. [PMID: 19632634 DOI: 10.1016/j.hrthm.2009.05.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2008] [Accepted: 05/08/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND The predictive value of ECG QT interval for mortality in the general population has been weak. Only a few population studies on the predictive value of ECG T-wave morphology parameters for mortality have been reported. OBJECTIVE The purpose of this study was to examine the predictive value of ECG QT interval and T-wave morphology parameters for all-cause and cardiovascular mortality in the general population. METHODS The prognostic values of ECG QT interval and four T-wave morphology parameters (principal component analysis ratio, T-wave morphology dispersion, total cosine R-to-T, T-wave residuum) were assessed in 5,917 adults (45% men; age 52 +/- 14 years) participating in the Finnish population-based Health 2000 Study. RESULTS After a mean follow-up of 5.9 +/- 0.8 years, 335 deaths had occurred, including 131 cardiovascular deaths. QT interval and, with a few exceptions, all T-wave morphology parameters were significant univariate mortality predictors. In men, in Cox multivariate analyses, principal component analysis ratio and T-wave morphology dispersion remained as independent predictors of all-cause and cardiovascular mortality, with the above-median T-wave morphology dispersion group showing the highest risk of cardiovascular death (hazard ratio [HR] 4.4, 95% confidence interval [CI] 2.1-9.4). In women, independent mortality predictors were total cosine R-to-T (cardiovascular mortality) and T-wave residuum (all-cause and cardiovascular mortality), with the above-median T-wave residuum group showing the highest risk of cardiovascular death (HR 2.2, 95% CI 1.1-4.2). CONCLUSION In the general population, T-wave morphology parameters, but not heart rate-corrected QT interval, provide independent prognostic information on mortality. The prognostic value of T-wave morphology parameters is specifically related to cardiovascular mortality and seems to be gender specific.
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16
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Newton-Cheh C, Eijgelsheim M, Rice KM, de Bakker PIW, Yin X, Estrada K, Bis JC, Marciante K, Rivadeneira F, Noseworthy PA, Sotoodehnia N, Smith NL, Rotter JI, Kors JA, Witteman JCM, Hofman A, Heckbert SR, O'Donnell CJ, Uitterlinden AG, Psaty BM, Lumley T, Larson MG, Stricker BHC. Common variants at ten loci influence QT interval duration in the QTGEN Study. Nat Genet 2009; 41:399-406. [PMID: 19305408 PMCID: PMC2701449 DOI: 10.1038/ng.364] [Citation(s) in RCA: 330] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Accepted: 01/19/2009] [Indexed: 12/13/2022]
Abstract
QT interval duration, reflecting myocardial repolarization on the electrocardiogram, is a heritable risk factor for sudden cardiac death and drug-induced arrhythmias. We conducted a meta-analysis of three genome-wide association studies in 13,685 individuals of European ancestry from the Framingham Heart Study, the Rotterdam Study and the Cardiovascular Health Study, as part of the QTGEN consortium. We observed associations at P < 5 x 10(-8) with variants in NOS1AP, KCNQ1, KCNE1, KCNH2 and SCN5A, known to be involved in myocardial repolarization and mendelian long-QT syndromes. Associations were found at five newly identified loci, including 16q21 near NDRG4 and GINS3, 6q22 near PLN, 1p36 near RNF207, 16p13 near LITAF and 17q12 near LIG3 and RFFL. Collectively, the 14 independent variants at these 10 loci explain 5.4-6.5% of the variation in QT interval. These results, together with an accompanying paper, offer insights into myocardial repolarization and suggest candidate genes that could predispose to sudden cardiac death and drug-induced arrhythmias.
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Affiliation(s)
- Christopher Newton-Cheh
- Center for Human Genetic Research, Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA.
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17
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Chugh SS, Reinier K, Singh T, Uy-Evanado A, Socoteanu C, Peters D, Mariani R, Gunson K, Jui J. Determinants of prolonged QT interval and their contribution to sudden death risk in coronary artery disease: the Oregon Sudden Unexpected Death Study. Circulation 2009; 119:663-70. [PMID: 19171855 DOI: 10.1161/circulationaha.108.797035] [Citation(s) in RCA: 184] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In a recent cohort study, prolongation of the corrected QT interval (QTc) was associated with an independent increased risk of sudden cardiac death (SCD). We evaluated determinants of prolonged QTc and the relationship of prolonged QTc to SCD risk among patients with coronary artery disease in the general population. METHODS AND RESULTS A case-control design was used. Cases were SCD patients with coronary artery disease among a metropolitan area of 1 000 000 residents (2002 to 2006); controls were area residents with coronary artery disease but no history of SCD. All cases were required to have an ECG suitable for QTc analysis before and unrelated to the occurrence of SCD. A total of 373 cases and 309 controls met criteria for analysis. Mean QTc was significantly longer in cases than in controls (450+/-45 versus 433+/-37 ms; P<0.0001). In a multivariate model, gender, diabetes mellitus, and QTc-prolonging drugs were significant determinants of QTc prolongation in controls. In a logistic regression model predicting SCD, diabetes mellitus (odds ratio, 1.97; 95% confidence interval, 1.32 to 2.96) and use of QTc-prolonging drugs (odds ratio, 2.90; 95% confidence interval, 1.92 to 4.37) were significant predictors of SCD among subjects with normal or borderline QTc. However, abnormally prolonged QTc in the absence of diabetes and QT-prolonging medications was the strongest predictor of SCD (odds ratio, 5.53; 95% confidence interval, 3.20 to 9.57). CONCLUSIONS Diabetes mellitus and QTc-affecting drugs determined QTc prolongation and were predictors of SCD in coronary artery disease. However, idiopathic abnormal QTc prolongation was associated with 5-fold increased odds of SCD. A continued search for novel determinants of QTc prolongation such as genomic factors is likely to enhance risk stratification for SCD in coronary artery disease.
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Affiliation(s)
- Sumeet S Chugh
- Cardiac Arrhythmia Center, Division of Cardiovascular Medicine, Oregon Health and Science University, Portland, USA.
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18
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Affiliation(s)
- Peter A. Noseworthy
- From the Cardiology Division (P.A.N., C.N.-C.), the Center for Human Genetic Research (C.N.-C.), and Cardiovascular Research Center (C.N.-C.), Massachusetts General Hospital, Harvard Medical School, Boston, Mass; and the Program in Medical and Population Genetics, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, Mass (C.N.-C.)
| | - Christopher Newton-Cheh
- From the Cardiology Division (P.A.N., C.N.-C.), the Center for Human Genetic Research (C.N.-C.), and Cardiovascular Research Center (C.N.-C.), Massachusetts General Hospital, Harvard Medical School, Boston, Mass; and the Program in Medical and Population Genetics, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, Mass (C.N.-C.)
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19
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Newton-Cheh C, Guo CY, Larson MG, Musone SL, Surti A, Camargo AL, Drake JA, Benjamin EJ, Levy D, D'Agostino RB, Hirschhorn JN, O'donnell CJ. Common Genetic Variation in
KCNH2
Is Associated With QT Interval Duration. Circulation 2007; 116:1128-36. [PMID: 17709632 DOI: 10.1161/circulationaha.107.710780] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
QT prolongation is associated with increased risk of sudden cardiac death in the general population and in people exposed to QT-prolonging drugs. Mutations in the
KCNH2
gene encoding the HERG potassium channel cause 30% of long-QT syndrome, and binding to this channel leads to drug-induced QT prolongation. We tested common
KCNH2
variants for association with continuous QT interval duration.
Methods and Results—
We selected 17 single nucleotide polymorphisms and rs1805123, a previously associated missense single nucleotide polymorphism, for genotyping in 1730 unrelated men and women from the Framingham Heart Study. rs3807375 genotypes were associated with continuous QT interval duration in men and women (2-
df
P
=0.002), with a dominant model suggested (
P
=0.0004). An independent sample of 871 Framingham Heart Study men and women replicated the association (1-sided dominant
P
=0.02). On combined analysis of 2123 subjects, individuals with AA or AG genotypes had a 0.14-SD (SE, 0.04) or 3.9-ms higher age-, sex- and RR-adjusted QT interval compared with GG individuals (
P
=0.00006). The previously reported association of rs1805123 (K897T) replicated under a dominant (AA/AC, 0.12 SD [SE, 0.07] or 3.1 ms higher versus CC; 1-sided
P
=0.04) or additive model (0.06 SD [SE, 0.03] or 1.6 ms higher per A allele; 1-sided
P
=0.01).
Conclusions—
Two common genetic variants at the
KCNH2
locus are associated with continuous QT interval duration in an unselected community-based sample. Studies to determine the influence of these variants on risk of sudden cardiac death and drug-induced arrhythmias should be considered.
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21
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Saikawa T, Nakagawa M, Takahashi N. QT Interval Revisited-Not Just the Matter of "Interval," but "Dynamics, Variability and Morphology" Matter!-. J Arrhythm 2007. [DOI: 10.4020/jhrs.23.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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22
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Saikawa T, Nakagawa M, Takahashi N. QT Interval Revisited —Not Just the Matter of “Interval,” but “Dynamics, Variability and Morphology” Matter!—. J Arrhythm 2007. [DOI: 10.1016/s1880-4276(07)80002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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