1
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Simon ST, Lin M, Trinkley KE, Aleong R, Rafaels N, Crooks KR, Reiter MJ, Gignoux CR, Rosenberg MA. A polygenic risk score for the QT interval is an independent predictor of drug-induced QT prolongation. PLoS One 2024; 19:e0303261. [PMID: 38885227 PMCID: PMC11182491 DOI: 10.1371/journal.pone.0303261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 04/23/2024] [Indexed: 06/20/2024] Open
Abstract
Drug-induced QT prolongation (diLQTS), and subsequent risk of torsade de pointes, is a major concern with use of many medications, including for non-cardiac conditions. The possibility that genetic risk, in the form of polygenic risk scores (PGS), could be integrated into prediction of risk of diLQTS has great potential, although it is unknown how genetic risk is related to clinical risk factors as might be applied in clinical decision-making. In this study, we examined the PGS for QT interval in 2500 subjects exposed to a known QT-prolonging drug on prolongation of the QT interval over 500ms on subsequent ECG using electronic health record data. We found that the normalized QT PGS was higher in cases than controls (0.212±0.954 vs. -0.0270±1.003, P = 0.0002), with an unadjusted odds ratio of 1.34 (95%CI 1.17-1.53, P<0.001) for association with diLQTS. When included with age and clinical predictors of QT prolongation, we found that the PGS for QT interval provided independent risk prediction for diLQTS, in which the interaction for high-risk diagnosis or with certain high-risk medications (amiodarone, sotalol, and dofetilide) was not significant, indicating that genetic risk did not modify the effect of other risk factors on risk of diLQTS. We found that a high-risk cutoff (QT PGS ≥ 2 standard deviations above mean), but not a low-risk cutoff, was associated with risk of diLQTS after adjustment for clinical factors, and provided one method of integration based on the decision-tree framework. In conclusion, we found that PGS for QT interval is an independent predictor of diLQTS, but that in contrast to existing theories about repolarization reserve as a mechanism of increasing risk, the effect is independent of other clinical risk factors. More work is needed for external validation in clinical decision-making, as well as defining the mechanism through which genes that increase QT interval are associated with risk of diLQTS.
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Affiliation(s)
- Steven T. Simon
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Meng Lin
- Colorado Center for Personalized Medicine, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Katy E. Trinkley
- Department of Clinical Pharmacy, School of Pharmacy, University of Colorado, Aurora, CO, United States of America
| | - Ryan Aleong
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Nicholas Rafaels
- Colorado Center for Personalized Medicine, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Kristy R. Crooks
- Colorado Center for Personalized Medicine, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Michael J. Reiter
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Christopher R. Gignoux
- Colorado Center for Personalized Medicine, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Michael A. Rosenberg
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, United States of America
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2
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Park JY, Yu J, Kim CS, Baek JW, Jo Y, Kim YK. Effect of pneumatic leg compression on post-induction hypotension in elderly patients undergoing robot-assisted laparoscopic prostatectomy: a double-blind randomised controlled trial. Anaesthesia 2023; 78:730-738. [PMID: 36855947 DOI: 10.1111/anae.15994] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 03/02/2023]
Abstract
Post-induction hypotension is common and associated with postoperative complications. We hypothesised that pneumatic leg compression reduces post-induction hypotension in elderly patients undergoing robot-assisted laparoscopic prostatectomy. In this double-blind randomised study, patients were allocated randomly to the pneumatic leg compression group (n = 50) or control (n = 50). In the intervention group, pneumatic leg compression was initiated before induction of anaesthesia. In the control group, pneumatic leg compression was initiated 20 min after anaesthesia induction. The primary outcome was the incidence of post-induction hypotension in these groups. Post-induction hypotension was defined as systolic blood pressure < 90 mmHg during the first 20 min after induction. Haemodynamic variables and area under the curve of post-induction systolic blood pressure over time were assessed. Complications associated with pneumatic leg compression were recorded, including: peripheral neuropathy; compartment syndrome; extensive bullae beneath the leg sleeves; and pulmonary thromboembolism. The incidence of post-induction hypotension decreased in the pneumatic leg compression group compared with that in the control group; 5 (10%) vs. 29 (58%), respectively, p < 0.001. In the pneumatic leg compression group, the lowest systolic, diastolic and mean blood pressures 20 min after induction of anaesthesia were significantly greater than the control group. Pneumatic leg compression resulted in an increased area under the curve of systolic blood pressure in the first 20 min after induction, p = 0.001. There were no pneumatic leg compression-related complications. Pneumatic leg compression reduced post-induction hypotension in elderly patients undergoing robot-assisted laparoscopic prostatectomy, suggesting that it is an effective and safe intervention to prevent post-induction hypotension among elderly patients undergoing general anaesthesia.
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Affiliation(s)
- J-Y Park
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - J Yu
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - C-S Kim
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - J-W Baek
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Y Jo
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Y-K Kim
- Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
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3
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TeBay C, Hill AP, Windley MJ. Metabolic and electrolyte abnormalities as risk factors in drug-induced long QT syndrome. Biophys Rev 2022; 14:353-367. [PMID: 35103080 PMCID: PMC8792523 DOI: 10.1007/s12551-022-00929-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/04/2022] [Indexed: 02/06/2023] Open
Abstract
Drug-induced long QT syndrome (diLQTS) is the phenomenon by which the administration of drugs causes prolongation of cardiac repolarisation and leads to an increased risk of the ventricular tachycardia known as torsades de pointes (TdP). In most cases of diLQTS, the primary molecular target is the human ether-à-go-go-related gene protein (hERG) potassium channel, which carries the rapid delayed rectifier current (IKr) in the heart. However, the proarrhythmic risk associated with drugs that block hERG can be modified in patients by a range of environmental- and disease-related factors, such as febrile temperatures, alterations in pH, dyselectrolytaemias such as hypokalaemia and hypomagnesemia and coadministration with other drugs. In this review, we will discuss the clinical occurrence of drug-induced LQTS in the context of these modifying factors as well as the mechanisms by which they contribute to altered hERG potency and proarrhythmic risk.
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Affiliation(s)
- Clifford TeBay
- Victor Chang Cardiac Research Institute, 405, Liverpool street, Darlinghurst, Sydney, NSW 2020 Australia
| | - Adam P. Hill
- Victor Chang Cardiac Research Institute, 405, Liverpool street, Darlinghurst, Sydney, NSW 2020 Australia
- St. Vincent’s Clinical School, UNSW Sydney, Sydney, Australia
| | - Monique J. Windley
- Victor Chang Cardiac Research Institute, 405, Liverpool street, Darlinghurst, Sydney, NSW 2020 Australia
- St. Vincent’s Clinical School, UNSW Sydney, Sydney, Australia
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4
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Belbachir N, Cunningham N, Wu JC. High-Throughput Analysis of Drug Safety Responses in Induced Pluripotent Stem Cell-Derived Cardiomyocytes Using Multielectrode Array. Methods Mol Biol 2022; 2485:99-109. [PMID: 35618901 DOI: 10.1007/978-1-0716-2261-2_7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Microelectrode array (MEA) is an electrophysiological instrument used to track activities of ion channels in excitable cells. Neurons and cardiomyocytes are seeded to form a cell monolayer on a field of sensors able to detect electrical signals, called extracellular field potentials (EFPs). This noninvasive tool allows researchers to investigate key parameters such as EFP amplitude, duration, and arrhythmias. MEA is progressively considered the gold standard for high-throughput in vitro electrophysiological evaluation, particularly for cardiac disease modeling and cardiac toxicity assessment.
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Affiliation(s)
- Nadjet Belbachir
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA, USA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Nathan Cunningham
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA, USA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Joseph C Wu
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA, USA.
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA.
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
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5
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Funck-Brentano C, Salem JE. Influence of baseline QTc on sotalol-induced prolongation of ventricular repolarization in men and women. Br J Clin Pharmacol 2021; 88:3510-3515. [PMID: 34921433 DOI: 10.1111/bcp.15188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/23/2021] [Accepted: 12/01/2021] [Indexed: 11/28/2022] Open
Abstract
The extent of sotalol-induced QTc prolongation on the electrocardiogram, is variable among subjects and influenced by sex. However, the influence of baseline QTc on the extent of drug-induced QTc prolongation remains unclear. This was studied around peak plasma concentration in a large cohort of 376 healthy male and 614 healthy female subjects who received 80 mg of sotalol orally. Baseline QTc was 379±16ms in men and 393±15ms in women (p<0.0001). The change in QTc from baseline was highly variable among both sexes and was greater in women than in men (26.5±13.2 vs.13.0±10.8ms; <0.0001). The slope of the regression line between QTc on sotalol and baseline QTc did not significantly differ from unity in men and in women indicating that the extent of QTc prolongation with sotalol was not influenced by baseline QTc. Assessing QTc after administration of an IKr blocker may be more important than measuring a baseline QTc.
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Affiliation(s)
- Christian Funck-Brentano
- Sorbonne Université, Institut national de la santé et de la recherche médicale (INSERM), Assistance Publique - Hôpitaux de Paris (AP-HP), Clinical Investigation Center (CIC-1901), Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France
| | - Joe-Elie Salem
- Sorbonne Université, Institut national de la santé et de la recherche médicale (INSERM), Assistance Publique - Hôpitaux de Paris (AP-HP), Clinical Investigation Center (CIC-1901), Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France.,Departments of Medicine and Pharmacology, Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, TN, USA.,AP-HP Sorbonne Université, UNICO-GRECO, Cardio-Oncology Program, Sorbonne Université, Paris, France
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6
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TeBay C, McArthur JR, Mangala M, Kerr N, Heitmann S, Perry MD, Windley MJ, Vandenberg JI, Hill AP. Pathophysiological metabolic changes associated with disease modify the proarrhythmic risk profile of drugs with potential to prolong repolarisation. Br J Pharmacol 2021; 179:2631-2646. [PMID: 34837219 DOI: 10.1111/bph.15757] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE Hydroxychloroquine, chloroquine and azithromycin are three drugs that were proposed to treat COVID-19. While concern already existed around their proarrhythmic potential there is little data regarding how altered physiological states encountered in patients such as febrile state, electrolyte imbalances or acidosis might change their risk profiles. EXPERIMENTAL APPROACH Potency of hERG block was measured using high-throughput electrophysiology in the presence of variable environmental factors. These potencies informed simulations to predict population risk profiles. Effects on cardiac repolarisation were verified in human induced pluripotent stem cell-derived cardiomyocytes from multiple individuals. KEY RESULTS Chloroquine and hydroxychloroquine blocked hERG with IC50 of 1.47±0.07 μM and 3.78±0.17 μM respectively, indicating proarrhythmic risk at concentrations effective against SARS-CoV-2 in vitro. Hypokalaemia and hypermagnesemia increased potency of chloroquine and hydroxychloroquine, indicating increased proarrhythmic risk. Acidosis significantly reduced potency of all drugs, whereas increased temperature decreased potency of chloroquine and hydroxychloroquine against hERG but increased potency for azithromycin. In silico simulations demonstrated that proarrhythmic risk was increased by female sex, hypokalaemia and heart failure, and identified specific genetic backgrounds associated with emergence of arrhythmia. CONCLUSION AND IMPLICATIONS Our study demonstrates how proarrhythmic risk can be exacerbated by metabolic changes and pre-existing disease. More broadly, the study acts as a blueprint for how high-throughput in vitro screening, combined with in silico simulations can help guide both preclinical screening and clinical management of patients in relation to drugs with potential to prolong repolarisation.
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Affiliation(s)
- Clifford TeBay
- Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Jeffrey R McArthur
- Victor Chang Cardiac Research Institute, Sydney, Australia.,Illawarra Health and Medical Research Institute, University of Wollongong, Australia
| | - Melissa Mangala
- Victor Chang Cardiac Research Institute, Sydney, Australia.,St. Vincent's Clinical school, UNSW Sydney, Sydney, Australia
| | - Nicholas Kerr
- Victor Chang Cardiac Research Institute, Sydney, Australia.,St. Vincent's Clinical school, UNSW Sydney, Sydney, Australia
| | | | - Matthew D Perry
- Victor Chang Cardiac Research Institute, Sydney, Australia.,School of Medical Sciences, UNSW Sydney, Sydney, Australia
| | - Monique J Windley
- Victor Chang Cardiac Research Institute, Sydney, Australia.,St. Vincent's Clinical school, UNSW Sydney, Sydney, Australia
| | - Jamie I Vandenberg
- Victor Chang Cardiac Research Institute, Sydney, Australia.,St. Vincent's Clinical school, UNSW Sydney, Sydney, Australia
| | - Adam P Hill
- Victor Chang Cardiac Research Institute, Sydney, Australia.,St. Vincent's Clinical school, UNSW Sydney, Sydney, Australia
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7
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Prediction of arrhythmia susceptibility through mathematical modeling and machine learning. Proc Natl Acad Sci U S A 2021; 118:2104019118. [PMID: 34493665 DOI: 10.1073/pnas.2104019118] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/04/2021] [Indexed: 01/08/2023] Open
Abstract
At present, the QT interval on the electrocardiographic (ECG) waveform is the most common metric for assessing an individual's susceptibility to ventricular arrhythmias, with a long QT, or, at the cellular level, a long action potential duration (APD) considered high risk. However, the limitations of this simple approach have long been recognized. Here, we sought to improve prediction of arrhythmia susceptibility by combining mechanistic mathematical modeling with machine learning (ML). Simulations with a model of the ventricular myocyte were performed to develop a large heterogenous population of cardiomyocytes (n = 10,586), and we tested each variant's ability to withstand three arrhythmogenic triggers: 1) block of the rapid delayed rectifier potassium current (IKr Block), 2) augmentation of the L-type calcium current (ICaL Increase), and 3) injection of inward current (Current Injection). Eight ML algorithms were trained to predict, based on simulated AP features in preperturbed cells, whether each cell would develop arrhythmic dynamics in response to each trigger. We found that APD can accurately predict how cells respond to the simple Current Injection trigger but cannot effectively predict the response to IKr Block or ICaL Increase. ML predictive performance could be improved by incorporating additional AP features and simulations of additional experimental protocols. Importantly, we discovered that the most relevant features and experimental protocols were trigger specific, which shed light on the mechanisms that promoted arrhythmia formation in response to the triggers. Overall, our quantitative approach provides a means to understand and predict differences between individuals in arrhythmia susceptibility.
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8
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Campana C, Dariolli R, Boutjdir M, Sobie EA. Inflammation as a Risk Factor in Cardiotoxicity: An Important Consideration for Screening During Drug Development. Front Pharmacol 2021; 12:598549. [PMID: 33953668 PMCID: PMC8091045 DOI: 10.3389/fphar.2021.598549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 03/31/2021] [Indexed: 01/08/2023] Open
Abstract
Numerous commonly prescribed drugs, including antiarrhythmics, antihistamines, and antibiotics, carry a proarrhythmic risk and may induce dangerous arrhythmias, including the potentially fatal Torsades de Pointes. For this reason, cardiotoxicity testing has become essential in drug development and a required step in the approval of any medication for use in humans. Blockade of the hERG K+ channel and the consequent prolongation of the QT interval on the ECG have been considered the gold standard to predict the arrhythmogenic risk of drugs. In recent years, however, preclinical safety pharmacology has begun to adopt a more integrative approach that incorporates mathematical modeling and considers the effects of drugs on multiple ion channels. Despite these advances, early stage drug screening research only evaluates QT prolongation in experimental and computational models that represent healthy individuals. We suggest here that integrating disease modeling with cardiotoxicity testing can improve drug risk stratification by predicting how disease processes and additional comorbidities may influence the risks posed by specific drugs. In particular, chronic systemic inflammation, a condition associated with many diseases, affects heart function and can exacerbate medications’ cardiotoxic effects. We discuss emerging research implicating the role of inflammation in cardiac electrophysiology, and we offer a perspective on how in silico modeling of inflammation may lead to improved evaluation of the proarrhythmic risk of drugs at their early stage of development.
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Affiliation(s)
- Chiara Campana
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Rafael Dariolli
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Mohamed Boutjdir
- Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn, NY, United States.,Department of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn, NY, United States.,Department of Medicine, New York University School of Medicine, New York, NY, United States
| | - Eric A Sobie
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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9
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Ni H, Morotti S, Grandi E. A Heart for Diversity: Simulating Variability in Cardiac Arrhythmia Research. Front Physiol 2018; 9:958. [PMID: 30079031 PMCID: PMC6062641 DOI: 10.3389/fphys.2018.00958] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/29/2018] [Indexed: 12/31/2022] Open
Abstract
In cardiac electrophysiology, there exist many sources of inter- and intra-personal variability. These include variability in conditions and environment, and genotypic and molecular diversity, including differences in expression and behavior of ion channels and transporters, which lead to phenotypic diversity (e.g., variable integrated responses at the cell, tissue, and organ levels). These variabilities play an important role in progression of heart disease and arrhythmia syndromes and outcomes of therapeutic interventions. Yet, the traditional in silico framework for investigating cardiac arrhythmias is built upon a parameter/property-averaging approach that typically overlooks the physiological diversity. Inspired by work done in genetics and neuroscience, new modeling frameworks of cardiac electrophysiology have been recently developed that take advantage of modern computational capabilities and approaches, and account for the variance in the biological data they are intended to illuminate. In this review, we outline the recent advances in statistical and computational techniques that take into account physiological variability, and move beyond the traditional cardiac model-building scheme that involves averaging over samples from many individuals in the construction of a highly tuned composite model. We discuss how these advanced methods have harnessed the power of big (simulated) data to study the mechanisms of cardiac arrhythmias, with a special emphasis on atrial fibrillation, and improve the assessment of proarrhythmic risk and drug response. The challenges of using in silico approaches with variability are also addressed and future directions are proposed.
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Affiliation(s)
| | | | - Eleonora Grandi
- Department of Pharmacology, University of California, Davis, Davis, CA, United States
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10
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Aromolaran AS, Boutjdir M. Cardiac Ion Channel Regulation in Obesity and the Metabolic Syndrome: Relevance to Long QT Syndrome and Atrial Fibrillation. Front Physiol 2017; 8:431. [PMID: 28680407 PMCID: PMC5479057 DOI: 10.3389/fphys.2017.00431] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/06/2017] [Indexed: 01/03/2023] Open
Abstract
Obesity and its associated metabolic dysregulation leading to metabolic syndrome is an epidemic that poses a significant public health problem. More than one-third of the world population is overweight or obese leading to enhanced risk of cardiovascular disease (CVD) incidence and mortality. Obesity predisposes to atrial fibrillation, ventricular, and supraventricular arrhythmias; conditions that are underlain by dysfunction in electrical activity of the heart. To date, current therapeutic options for cardiomyopathy of obesity are limited, suggesting that there is considerable room for development of therapeutic interventions with novel mechanisms of action that will help normalize rhythm in obese patients. Emerging candidates for modulation by obesity are cardiac ion channels and Ca handling proteins. However, the underlying molecular mechanisms of the impact of obesity on these channels/Ca handling proteins remain incompletely understood. Obesity is marked by accumulation of adipose tissue associated with a variety of adverse adaptations including dyslipidemia (or abnormal levels of serum free fatty acids), increased secretion of pro-inflammatory cytokines, fibrosis, hyperglycemia, and insulin resistance, that will cause electrical remodeling and thus predispose to arrhythmias. Further, adipose tissue is also associated with the accumulation of subcutaneous and visceral fat, which are marked by distinct signaling mechanisms. Thus, there may also be functional differences in the outcome of regional distribution of fat deposits on ion channel/Ca handling proteins expression. Evaluating alterations in their functional expression in obesity will lead to progress in the knowledge about the mechanisms responsible for obesity-related arrhythmias. These advances are likely to reveal new targets for pharmacological modulation. The objective of this article is to review cardiac ion channel/Ca handling proteins remodeling that predispose to arrhythmias. Understanding how obesity and related mechanisms lead to cardiac electrical remodeling is likely to have a significant medical and economic impact.
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Affiliation(s)
- Ademuyiwa S Aromolaran
- Cardiovascular Research Program, VA New York Harbor Healthcare SystemBrooklyn, NY, United States.,Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical CenterBrooklyn, NY, United States
| | - Mohamed Boutjdir
- Cardiovascular Research Program, VA New York Harbor Healthcare SystemBrooklyn, NY, United States.,Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical CenterBrooklyn, NY, United States.,Department of Medicine, New York University School of MedicineNew York, NY, United States
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11
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Chorin E, Hochstadt A, Viskin S, Rozovski U, Havakuk O, Baranchuk A, Enriquez A, Strasberg B, Guevara-Valdivia ME, Márquez MF, González-Pacheco H, Hasdemir C, Rosso R. Female gender as independent risk factor of torsades de pointes during acquired atrioventricular block. Heart Rhythm 2017; 14:90-95. [DOI: 10.1016/j.hrthm.2016.09.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Indexed: 11/29/2022]
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12
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Abstract
A prolonged QT interval is an important risk factor for ventricular arrhythmias and sudden cardiac death. QT prolongation can be caused by drugs. There are multiple risk factors for drug-induced QT prolongation, including genetic variation. QT prolongation is one of the most common reasons for withdrawal of drugs from the market, despite the fact that these drugs may be beneficial for certain patients and not harmful in every patient. Identifying genetic variants associated with drug-induced QT prolongation might add to tailored pharmacotherapy and prevent beneficial drugs from being withdrawn unnecessarily. In this review, our objective was to provide an overview of the genetic background of drug-induced QT prolongation, distinguishing pharmacokinetic and pharmacodynamic pathways. Pharmacokinetic-mediated genetic susceptibility is mainly characterized by variation in genes encoding drug-metabolizing cytochrome P450 enzymes or drug transporters. For instance, the P-glycoprotein drug transporter plays a role in the pharmacokinetic susceptibility of drug-induced QT prolongation. The pharmacodynamic component of genetic susceptibility is mainly characterized by genes known to be associated with QT interval duration in the general population and genes in which the causal mutations of congenital long QT syndromes are located. Ethnicity influences susceptibility to drug-induced QT interval prolongation, with Caucasians being more sensitive than other ethnicities. Research on the association between pharmacogenetic interactions and clinical endpoints such as sudden cardiac death is still limited. Future studies in this area could enable us to determine the risk of arrhythmias more adequately in clinical practice.
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13
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GARABELLI PAUL, STAVRAKIS STAVROS, ALBERT MICHAEL, KOOMSON EDWARD, PARWANI PURVI, CHOHAN JAWAD, SMITH LANDGRAVE, ALBERT DAVID, XIE RONGSHENG, XIE QIYING, REYNOLDS DWIGHT, PO SUNNY. Comparison of QT Interval Readings in Normal Sinus Rhythm Between a Smartphone Heart Monitor and a 12-Lead ECG for Healthy Volunteers and Inpatients Receiving Sotalol or Dofetilide. J Cardiovasc Electrophysiol 2016; 27:827-32. [DOI: 10.1111/jce.12976] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 03/13/2016] [Accepted: 03/22/2016] [Indexed: 11/28/2022]
Affiliation(s)
- PAUL GARABELLI
- Section of Cardiovascular Diseases and Heart Rhythm Institute; University of Oklahoma Health Sciences Center; Oklahoma City Oklahoma USA
| | - STAVROS STAVRAKIS
- Section of Cardiovascular Diseases and Heart Rhythm Institute; University of Oklahoma Health Sciences Center; Oklahoma City Oklahoma USA
| | - MICHAEL ALBERT
- Section of Cardiovascular Diseases and Heart Rhythm Institute; University of Oklahoma Health Sciences Center; Oklahoma City Oklahoma USA
| | - EDWARD KOOMSON
- Section of Cardiovascular Diseases and Heart Rhythm Institute; University of Oklahoma Health Sciences Center; Oklahoma City Oklahoma USA
| | | | - JAWAD CHOHAN
- Section of Cardiovascular Diseases and Heart Rhythm Institute; University of Oklahoma Health Sciences Center; Oklahoma City Oklahoma USA
| | | | | | - RONGSHENG XIE
- Section of Cardiovascular Diseases and Heart Rhythm Institute; University of Oklahoma Health Sciences Center; Oklahoma City Oklahoma USA
| | - QIYING XIE
- Section of Cardiovascular Diseases and Heart Rhythm Institute; University of Oklahoma Health Sciences Center; Oklahoma City Oklahoma USA
| | - DWIGHT REYNOLDS
- Section of Cardiovascular Diseases and Heart Rhythm Institute; University of Oklahoma Health Sciences Center; Oklahoma City Oklahoma USA
| | - SUNNY PO
- Section of Cardiovascular Diseases and Heart Rhythm Institute; University of Oklahoma Health Sciences Center; Oklahoma City Oklahoma USA
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14
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Taooka Y, Takezawa G, Ohe M, Sutani A, Isobe T. Multiple logistic regression analysis of risk factors in elderly pneumonia patients: QTc interval prolongation as a prognostic factor. Multidiscip Respir Med 2015; 9:59. [PMID: 25705382 PMCID: PMC4334847 DOI: 10.1186/2049-6958-9-59] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 09/30/2014] [Indexed: 11/10/2022] Open
Abstract
Background Acute pneumonia is a serious problem in the elderly and various risk factors have already been reported, but the involvement of QTc interval prolongation remains uncertain. The aim of this study was to elucidate the prognostic factors for the development of pneumonia in elderly patients and to study the possible involvement of QTc interval prolongation. Methods The subjects were 249 hospitalized pneumonia patients more than 65 years old in Aki-Ohta Hospital from January 2010 to December 2013. Community-acquired pneumonia patients and nursing care and healthcare-associated pneumonia patients were included in the study. The pneumonia severity index, vital signs, blood chemistry data and ECG findings were retrospectively compared using multiple logistic regression analysis. Results 39 patients died within 30 days from onset. The clinical features related to poor prognosis were: advanced age, past history of cerebral vascular disease and/or diabetes mellitus, decreased serum albumin level, higher CURB-65 or PORT index scores and QTc interval prolongation. Patients showing a prolonged QTc interval had a higher mortality than those with a normal QTc interval. A prolonged QTc interval was not related to serum calcium concentration and/or treatment with QTc prolongation drug, clarithromycin or azithromycin, but related to age, lower albumin concentration and past history of diabetes mellitus. Conclusions These findings suggest potential prognostic factors for pneumonia in elderly patients, including a prolonged QTc interval (> 0.44 seconds).
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Affiliation(s)
- Yasuyuki Taooka
- Department of General Medicine, Aki-Ohta Hospital, Shimodono-Gohchi 236, Aki-Ohta-Cho, Yamagata-Gun, Hiroshima, 731-3622 Japan ; Division of Clinical Oncology and Respiratory Medicine, Department of Internal Medicine, Shimane University Faculty of Medicine, Izumo, Japan
| | - Gen Takezawa
- Department of General Medicine, Aki-Ohta Hospital, Shimodono-Gohchi 236, Aki-Ohta-Cho, Yamagata-Gun, Hiroshima, 731-3622 Japan
| | - Miki Ohe
- Division of Clinical Oncology and Respiratory Medicine, Department of Internal Medicine, Shimane University Faculty of Medicine, Izumo, Japan
| | - Akihisa Sutani
- Division of Clinical Oncology and Respiratory Medicine, Department of Internal Medicine, Shimane University Faculty of Medicine, Izumo, Japan
| | - Takeshi Isobe
- Division of Clinical Oncology and Respiratory Medicine, Department of Internal Medicine, Shimane University Faculty of Medicine, Izumo, Japan
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Seong SJ, Yoon YR, Lim MS. Serious adverse events during clinical trial for pharmacokinetic interaction between telmisartan and chlorthalidone in healthy Korean subjects: A case report. Transl Clin Pharmacol 2015. [DOI: 10.12793/tcp.2015.23.2.46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Sook Jin Seong
- Department of Biomedical Science, BK21 Plus KNU Bio-Medical Convergence Program for Creative Talent and Clinical Trial Center, Kyungpook National University Graduate School and Hospital, Daegu 41944, Republic of Korea
| | - Young-Ran Yoon
- Department of Biomedical Science, BK21 Plus KNU Bio-Medical Convergence Program for Creative Talent and Clinical Trial Center, Kyungpook National University Graduate School and Hospital, Daegu 41944, Republic of Korea
| | - Mi-sun Lim
- College of Pharmacy, Yeungnam University, 280 Daehak-ro, Gyeongsan, Gyeongbuk 42415, Republic of Korea
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Darpo B, Karnad DR, Badilini F, Florian J, Garnett CE, Kothari S, Panicker GK, Sarapa N. Are women more susceptible than men to drug-induced QT prolongation? Concentration-QTc modelling in a phase 1 study with oral rac-sotalol. Br J Clin Pharmacol 2014; 77:522-31. [PMID: 23819796 DOI: 10.1111/bcp.12201] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 04/18/2013] [Indexed: 11/28/2022] Open
Abstract
AIM To study the differences in QTc interval on ECG in response to a single oral dose of rac-sotalol in men and women. METHODS Continuous 12-lead ECGs were recorded in 28 men and 11 women on a separate baseline day and following a single oral dose of 160 mg rac-sotalol on the following day. ECGs were extracted at prespecified time points and upsampled to 1000 Hz and analyzed manually in a central ECG laboratory on the superimposed median beat. Concentration-QTc analyses were performed using a linear mixed effects model. RESULTS Rac-sotalol produced a significant reduction in heart rate in men and in women. An individual correction method (QTc I) most effectively removed the heart rate dependency of the QTc interval. Mean QTc I was 10 to 15 ms longer in women at all time points on the baseline day. Rac-sotalol significantly prolonged QTc I in both genders. The largest mean change in QTc I (ΔQTc I) was greater in females (68 ms (95% confidence interval (CI) 59, 76 ms) vs. 27 ms (95% CI 22, 32 ms) in males). Peak rac-sotalol plasma concentration was higher in women than in men (mean Cmax 1.8 μg ml(-1) (range 1.1-2.8) vs. 1.4 μg ml(-1) (range 0.9-1.9), P = 0.0009). The slope of the concentration-ΔQTc I relationship was steeper in women (30 ms per μg ml(-1) vs. 23 ms per μg ml(-1) in men; P = 0.0135). CONCLUSIONS The study provides evidence for a greater intrinsic sensitivity to rac-sotalol in women than in men for drug-induced delay in cardiac repolarization.
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Affiliation(s)
- Borje Darpo
- Karolinska Institute, Department of Clinical Sciences, Danderyd's Hospital, Division of Cardiovascular Medicine, Stockholm, Sweden
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Hasnain M, Vieweg WVR, Howland RH, Kogut C, Breden Crouse EL, Koneru JN, Hancox JC, Digby GC, Baranchuk A, Deshmukh A, Pandurangi AK. Quetiapine, QTc interval prolongation, and torsade de pointes: a review of case reports. Ther Adv Psychopharmacol 2014; 4:130-8. [PMID: 25057346 PMCID: PMC4107702 DOI: 10.1177/2045125313510194] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Recently, both the manufacturer of quetiapine and the US Food and Drug Administration warned healthcare providers and patients about quetiapine-induced QTc interval prolongation and torsade de pointes (TdP) when using this drug within the approved labeling. We reviewed the case-report literature and found 12 case reports of QTc interval prolongation in the setting of quetiapine administration. There were no cases of quetiapine-induced TdP or sudden cardiac death (SCD) among patients using quetiapine appropriately and free of additional risk factors for QTc interval prolongation and TdP. Among the 12 case reports risk factors included female sex (nine cases), coadministration of a drug associated with QTc interval prolongation (eight cases), hypokalemia or hypomagnesemia (six cases) quetiapine overdose (five cases), cardiac problems (four cases), and coadministration of cytochrome P450 3A4 inhibitors (two cases). There were four cases of TdP. As drug-induced TdP is a rare event, prospective studies to evaluate the risk factors associated with QTc prolongation and TdP are difficult to design, would be very costly, and would require very large samples to capture TdP rather than its surrogate markers. Furthermore, conventional statistical methods may not apply to studies of TdP, which is rare and an 'outlier' manifestation of QTc prolongation. We urge drug manufacturers and regulatory agencies to periodically publish full case reports of psychotropic drug-induced QTc interval prolongation, TdP, and SCD so that clinicians and investigators may better understand the clinical implications of prescribing such drugs as quetiapine.
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Affiliation(s)
- Mehrul Hasnain
- Department of Psychiatry, Memorial University, St John's, Newfoundland, Canada A1E4J8
| | - W Victor R Vieweg
- Departments of Psychiatry and Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Robert H Howland
- Department of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, PA, USA
| | - Christopher Kogut
- Departments of Psychiatry, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Jayanthi N Koneru
- Cardiac Electrophysiology and Department of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Geneviève C Digby
- Department of Cardiology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Adrian Baranchuk
- Department of Cardiology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Anand Deshmukh
- Department of Cardiovascular Medicine, The Cardiac Center of Creighton University, Omaha, NE, USA
| | - Ananda K Pandurangi
- Departments of Psychiatry, Virginia Commonwealth University, Richmond, VA, USA
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Lin NC, Huang CL, Chen CY, Lin TY, Wang HY, Lu YH, Chen LM, Chen VCH, Gossop M. Effect of amphetamine on corrected-QT interval change during methadone maintenance treatment in Taiwan: a prospective cohort study. Drug Alcohol Rev 2013; 33:194-201. [PMID: 24320220 DOI: 10.1111/dar.12099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 11/15/2013] [Indexed: 01/02/2023]
Abstract
INTRODUCTION AND AIMS Previous studies have suggested that methadone is associated with prolonged corrected-QT (QTc) interval, but published prospective research studies in this area are relatively scarce. This study investigates QTc interval change among methadone maintenance patients and possible associated risk factors. One of the aims is to explore the effect of amphetamines. DESIGN AND METHODS This prospective cohort study with six-month follow up assesses the effect of methadone on QTc interval among a sample (n = 170) of heroin users in a methadone maintenance treatment program in Taiwan. Demographic data, substance use history, medical history and laboratory studies were collected at study enrollment. Twelve-lead electrocardiograms were performed for all participants both at study enrollment and six months later. RESULTS The median daily methadone dose was 41 mg. A mean increase of QTc interval (17.1 ms, SD = 50.0, P < 0.001) was found at six-month follow up. QTc interval prolongation in the sample at baseline was 2.9%, and at six months was 12.4%. A positive correlation was found between comorbid amphetamine use frequency in the past month and QTc interval change. Methadone dose was not associated with QTc change. DISCUSSION AND CONCLUSIONS An increase of mean QTc interval was found among methadone maintenance patients at six-month follow up. Electrocardiogram monitoring should be performed among patients who are at risk of frequently using amphetamines during methadone maintenance treatment.
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Affiliation(s)
- Ni-Chi Lin
- Tsaotun Psychiatric Centre, Ministry of Health and Welfare, Nan-Tou, Taiwan
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20
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Korantzopoulos P, Letsas KP, Kotsia A, Baltogiannis G, Kalantzi K, Kyrlas K, Goudevenos JA. Ibutilide and novel indexes of ventricular repolarization in persistent atrial fibrillation patients. World J Cardiol 2013; 5:242-246. [PMID: 23888193 PMCID: PMC3722421 DOI: 10.4330/wjc.v5.i7.242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 05/15/2013] [Accepted: 06/04/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To examine the effect of ibutilide on novel indexes of repolarization in patients with persistent atrial fibrillation (AF).
METHODS: We studied consecutive patients scheduled for elective electrical cardioversion. Intravenous ibutilide (1 + 1 mg) was administered before the electrical cardioversion while close electrocardiographic (ECG) monitoring was performed. ECG indexes such as corrected QT interval (QTc), the interval from the peak until the end of T wave (Tpe), and the Tpe/QT ratio were measured before ibutilide infusion and 10 min after the end of infusion.
RESULTS: The final study population consisted of 20 patients (mean age: 67.1 ± 9.9 years, 10 men). Six patients were cardioverted pharmacologically and did not proceed to electrical cardioversion. Two patients developed short non-sustained episodes of torsades de pointes ventricular tachycardia. All but one of the aforementioned ECG indexes increased significantly after ibutilide administration. In specific, the QTc interval increased from 442 ± 29 to 471 ± 37 ms (P = 0.037), the Tpe interval in precordial leads from 96 ms (range 80-108 ms) to 101 ms (range 91-119 ms) (P = 0.021), the Tpe interval in lead II from 79 ms (range 70-88 ms) to 100 ms (range 87-104 ms) (P < 0.001), the Tpe/QT ratio in precordial leads from 0.23 ms (range 0.18-0.26 ms) to 0.26 ms (range 0.23-0.28 ms) (P = 0.028), and the Tpe interval dispersion from 25 ms (range 23-30 ms) to 35 ms (range 27-39 ms) (P = 0.012). However, the Tpe/QT ratio in lead II did not change significantly.
CONCLUSION: Ibutilide increases the duration and dispersion of ventricular repolarization. The prognostic value of Tpe and Tpe/QT in the setting of drug-induced proarrhythmia needs further study.
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21
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Shah RR. Drug-induced QT interval prolongation: does ethnicity of the thorough QT study population matter? Br J Clin Pharmacol 2013; 75:347-58. [PMID: 22882246 DOI: 10.1111/j.1365-2125.2012.04415.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 08/02/2012] [Indexed: 01/07/2023] Open
Abstract
Inter-ethnic differences in drug responses have been well documented. Drug-induced QT interval prolongation is a major safety concern and therefore, regulatory authorities recommend a clinical thorough QT study (TQT) to investigate new drugs for their QT-prolonging potential. A positive study, determined by breach of a preset regulatory threshold, significantly influences late phase clinical trials by requiring intense ECG monitoring. A few studies that are currently available, although not statistically conclusive at present, question the assumption that ethnicity of the study population may not influence the outcome of a TQT study. Collective consideration of available pharmacogenetic and clinical information suggests that there may be inter-ethnic differences in QT-prolonging effects of drugs and that Caucasians may be more sensitive than other populations. The information also suggest s that (a) these differences may depend on the QT-prolonging potency of the drug and (b) exposure-response (E-R) analysis may be more sensitive than simple changes in QT(c) interval in unmasking this difference. If the QT response in Caucasians is generally found to be more intense than in non-Caucasians, there may be significant regulatory implications for domestic acceptance of data from a TQT study conducted in foreign populations. However, each drug will warrant an individual consideration when extrapolating the results of a TQT study from one ethnic population to another and the ultimate clinical relevance of any difference. Further adequately designed and powered studies, investigating the pharmacologic properties and E-R relationships of additional drugs with different potencies, are needed in Caucasians, Oriental/Asian and African populations before firm conclusions can be drawn.
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Experimentally calibrated population of models predicts and explains intersubject variability in cardiac cellular electrophysiology. Proc Natl Acad Sci U S A 2013; 110:E2098-105. [PMID: 23690584 DOI: 10.1073/pnas.1304382110] [Citation(s) in RCA: 198] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Cellular and ionic causes of variability in the electrophysiological activity of hearts from individuals of the same species are unknown. However, improved understanding of this variability is key to enable prediction of the response of specific hearts to disease and therapies. Limitations of current mathematical modeling and experimental techniques hamper our ability to provide insight into variability. Here, we describe a methodology to unravel the ionic determinants of intersubject variability exhibited in experimental recordings, based on the construction and calibration of populations of models. We illustrate the methodology through its application to rabbit Purkinje preparations, because of their importance in arrhythmias and safety pharmacology assessment. We consider a set of equations describing the biophysical processes underlying rabbit Purkinje electrophysiology, and we construct a population of over 10,000 models by randomly assigning specific parameter values corresponding to ionic current conductances and kinetics. We calibrate the model population by closely comparing simulation output and experimental recordings at three pacing frequencies. We show that 213 of the 10,000 candidate models are fully consistent with the experimental dataset. Ionic properties in the 213 models cover a wide range of values, including differences up to ±100% in several conductances. Partial correlation analysis shows that particular combinations of ionic properties determine the precise shape, amplitude, and rate dependence of specific action potentials. Finally, we demonstrate that the population of models calibrated using data obtained under physiological conditions quantitatively predicts the action potential duration prolongation caused by exposure to four concentrations of the potassium channel blocker dofetilide.
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Cullington D, Dunford N, Beer S, Hobson N, Chattopadhyay S, John J. Double jeopardy. Indian Heart J 2013; 65:315-8. [DOI: 10.1016/j.ihj.2013.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 01/21/2013] [Accepted: 04/03/2013] [Indexed: 11/24/2022] Open
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Vieweg WVR, Hasnain M, Howland RH, Hettema JM, Kogut C, Wood MA, Pandurangi AK. Citalopram, QTc interval prolongation, and torsade de pointes. How should we apply the recent FDA ruling? Am J Med 2012; 125:859-68. [PMID: 22748401 DOI: 10.1016/j.amjmed.2011.12.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 12/01/2011] [Accepted: 12/01/2011] [Indexed: 10/28/2022]
Abstract
Recently, both the manufacturer of citalopram and the US Food and Drug Administration have warned health care providers and patients about new information implicating drug-induced QTc interval prolongation and torsade de pointes when using citalopram in doses >40 mg/day. This warning is not placed in the context of either benefits or risks in real-world clinical practice, leaving clinicians with an untenable choice between depriving patients of high-dose citalopram or malpractice litigation. We reviewed the literature and found no cases of citalopram-induced sudden cardiac death among patients taking up to 60 mg/day of citalopram and free of risk factors for QTc interval prolongation and torsade de pointes. Because psychotropic drug-induced sudden cardiac death is an outlier in the absence of identified risk factors for QTc interval prolongation and torsade de pointes, we do not believe current Phase 3 and Phase 4 studies provide sufficient information to limit current prescribing practices for citalopram (20 mg to 60 mg/day). We urge drug manufacturers and regulatory agencies to periodically publish full case reports of psychotropic drug-induced QTc interval prolongation, torsade de pointes, and sudden cardiac death so that clinicians and investigators may better understand the clinical implications of prescribing such drugs as citalopram.
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Affiliation(s)
- W Victor R Vieweg
- Department of Psychiatry, Virginia Commonwealth University, Richmond, 23238-5414, USA.
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Jamshidi Y, Nolte IM, Dalageorgou C, Zheng D, Johnson T, Bastiaenen R, Ruddy S, Talbott D, Norris KJ, Snieder H, George AL, Marshall V, Shakir S, Kannankeril PJ, Munroe PB, Camm AJ, Jeffery S, Roden DM, Behr ER. Common variation in the NOS1AP gene is associated with drug-induced QT prolongation and ventricular arrhythmia. J Am Coll Cardiol 2012; 60:841-50. [PMID: 22682551 PMCID: PMC3753216 DOI: 10.1016/j.jacc.2012.03.031] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 02/24/2012] [Accepted: 03/06/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES This study sought to determine whether variations in NOS1AP affect drug-induced long QT syndrome (LQTS). BACKGROUND Use of antiarrhythmic drugs is limited by the high incidence of serious adverse events including QT prolongation and torsades de pointes. NOS1AP gene variants play a role in modulating QT intervals in healthy subjects and severity of presentation in LQTS. METHODS This study carried out an association study using 167 single nucleotide polymorphisms (SNP) spanning the NOS1AP gene in 58 Caucasian patients experiencing drug-induced LQTS (dLQTS) and 87 Caucasian controls from the DARE (Drug-Induced Arrhythmia Risk Evaluation) study. RESULTS The rs10800397 SNP was significantly associated with dLQTS (odds ratio [OR]: 3.3, 99.95% confidence interval [CI]: 1.0 to 10.8, p = 3.7 × 10(-4)). The associations were more pronounced in the subgroup of amiodarone users, in which 3 SNPs, including rs10800397, were significantly associated (most significant SNP: rs10919035: OR: 5.5, 99.95% CI: 1.1 to 27.9, p = 3.0 × 10(-4)). We genotyped rs10919035 in an independent replication cohort of 28 amiodarone dLQTS cases versus 173 control subjects (meta-analysis of both studies: OR: 2.81, 99.95% CI: 1.62 to 4.89, p = 2.4 × 10(-4)). Analysis of corrected QT interval among 74 control subjects from our dataset showed a similar pattern of significance over the gene region as the case-control analysis. This pattern was confirmed in 1,480 control subjects from the BRIGHT (British Genetics of Hypertension Study) cohort (top SNP from DARE: rs12734991 in meta-analysis: increase in corrected QT interval per C allele: 9.1 ± 3.2 ms, p = 1.7 × 10(-4)). CONCLUSIONS These results provide the first demonstration that common variations in the NOS1AP gene are associated with a significant increase in the risk of dLQTS. This study suggests that common variations in the NOS1AP gene may have relevance for future pharmacogenomic applications in clinical practice permitting safer prescription of drugs for vulnerable patients.
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[Severe bacterial infection: increased mortality in elderly women with low body weight taking drugs prolonging the QTc interval]. Med Klin Intensivmed Notfmed 2012; 107:275-84. [PMID: 22543817 DOI: 10.1007/s00063-012-0107-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 01/25/2012] [Accepted: 03/19/2012] [Indexed: 01/08/2023]
Abstract
AIMS Women have a higher risk of acquired long QT syndrome which could be of vital importance in severe bacterial infections when macrolides or fluoroquinolones are administered. This study evaluated whether age, drugs prolonging the QTc interval and body weight were additional influencing factors on mortality in the critically ill with respect to gender. METHODS In an exploratory investigation 204 intensive care unit (ICU) patients (78 f, 126 m, 61.1±16.1 years) with severe bacterial infections were studied (mortality probability model II(0) 49.1±28%). Antibiotic therapy was carried out following standard guidelines. In 65.2% of patients potentially QTc prolonging drugs were administered for ≥48 h. Body weight was ascertained on ICU admission. RESULTS By comparable severity of illness and comparable effect of antibiotic therapy, age, QTc prolonging drugs and less body weight showed significant effects on survival in women (p<0.001, 0.008 and 0.009, respectively). For women mortality increased with age ≥60 years (p=0.01). The division between survival versus non-survival was intensified by addition of QTc prolonging medication and body weight. As such a best risk assessment in women was achieved if age, QTc prolonging therapy and less body weight were combined (p<0.001). In a direct comparison to men, women with at least two of these factors had a significantly poorer outcome (OR 2.37; 95% CI 1.13-4.98; p=0.022). CONCLUSIONS Age, QTc prolonging drugs and lower body weight can additionally increase mortality in critically ill women. If negative outcome is attributed to a higher dosage, an adjustment for body weight must be carried out. Until now it should be considered whether it would be better to replace QTc prolonging antibiotics in routinely performed drug alternation in elderly lean women.
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Sarkar AX, Christini DJ, Sobie EA. Exploiting mathematical models to illuminate electrophysiological variability between individuals. J Physiol 2012; 590:2555-67. [PMID: 22495591 DOI: 10.1113/jphysiol.2011.223313] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Across individuals within a population, several levels of variability are observed, from the differential expression of ion channels at the molecular level, to the various action potential morphologies observed at the cellular level, to divergent responses to drugs at the organismal level. However, the limited ability of experiments to probe complex interactions between components has hitherto hindered our understanding of the factors that cause a range of behaviours within a population. Variability is a challenging issue that is encountered in all physiological disciplines, but recent work suggests that novel methods for analysing mathematical models can assist in illuminating its causes. In this review, we discuss mathematical modelling studies in cardiac electrophysiology and neuroscience that have enhanced our understanding of variability in a number of key areas. Specifically, we discuss parameter sensitivity analysis techniques that may be applied to generate quantitative predictions based on considering behaviours within a population of models, thereby providing novel insight into variability. Our discussion focuses on four issues that have benefited from the utilization of these methods: (1) the comparison of different electrophysiological models of cardiac myocytes, (2) the determination of the individual contributions of different molecular changes in complex disease phenotypes, (3) the identification of the factors responsible for the variable response to drugs, and (4) the constraining of free parameters in electrophysiological models of heart cells. Together, the studies that we discuss suggest that rigorous analyses of mathematical models can generate quantitative predictions regarding how molecular-level variations contribute to functional differences between experimental samples. These strategies may be applicable not just in cardiac electrophysiology, but in a wide range of disciplines.
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Affiliation(s)
- Amrita X Sarkar
- Pharmacology and Systems Therapeutics, Mount Sinai School of Medicine, New York, NY 10029, USA
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Predicting the degree of drug-induced QT prolongation and the risk for torsades de pointes. Heart Rhythm 2011; 8:1535-6. [DOI: 10.1016/j.hrthm.2011.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Indexed: 11/22/2022]
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Sarkar AX, Sobie EA. Quantification of repolarization reserve to understand interpatient variability in the response to proarrhythmic drugs: a computational analysis. Heart Rhythm 2011; 8:1749-55. [PMID: 21699863 DOI: 10.1016/j.hrthm.2011.05.023] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 05/27/2011] [Indexed: 01/08/2023]
Abstract
BACKGROUND "Repolarization reserve" is frequently invoked to explain why potentially proarrhythmic drugs cause, across a population, a range of changes to cardiac action potentials (APs). However, the mechanisms underlying this interindividual variability are not understood quantitatively. OBJECTIVE The purpose of this study was to perform a novel analysis of mathematical models of ventricular myocytes to quantify repolarization reserve and gain insight into the factors responsible for variability in the response to proarrhythmic drugs. METHODS/RESULTS In several models of human or canine ventricular myocytes, variability was simulated by randomizing model parameters and running repeated simulations. With each randomly generated set of parameters, APs before and after simulated 75% block of the rapid delayed rectifier current (I(Kr)) were calculated. Multivariable regression was performed to determine how much each model parameter attenuated or exacerbated the AP prolongation caused by the I(Kr)-blocking drug. Simulations with a human ventricular myocyte model suggest that drug response is influenced most strongly by (1) the density of I(Kr), (2) the density of slow delayed rectifier current I(Ks), (3) the voltage dependence of I(Kr) inactivation, (4) the density of L-type Ca2+ current, and (5) the kinetics of I(Ks) activation. The analysis also identified mechanisms underlying nonintuitive behavior, such as ionic currents that prolong baseline APs but decrease drug-induced AP prolongation. Finally, the simulations provided quantitative insight into conditions that aggravate the drug response, such as silent ion channel mutations and heart failure. CONCLUSION These modeling results provide the first thorough quantification of repolarization reserve and improve our understanding of interindividual variability in adverse drug reactions.
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Affiliation(s)
- Amrita X Sarkar
- Pharmacology and Systems Therapeutics, Mount Sinai School of Medicine, New York, New York 10029, USA
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