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Arabia G, Bellicini MG, Cersosimo A, Memo M, Mazzarotto F, Inciardi RM, Cerini M, Chen LY, Aboelhassan M, Benzoni P, Mitacchione G, Bontempi L, Curnis A. Ion channel dysfunction and fibrosis in atrial fibrillation: Two sides of the same coin. Pacing Clin Electrophysiol 2024; 47:417-428. [PMID: 38375940 DOI: 10.1111/pace.14944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 01/10/2024] [Accepted: 01/23/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common heart rhythm disorder that is associated with an increased risk of stroke and heart failure (HF). Initially, an association between AF and ion channel dysfunction was identified, classifying the pathology as a predominantly electrical disease. More recently it has been recognized that fibrosis and structural atrial remodeling play a driving role in the development of this arrhythmia also in these cases. PURPOSE Understanding the role of fibrosis in genetic determined AF could be important to better comprise the pathophysiology of this arrhythmia and to refine its management also in nongenetic forms. In this review we analyze genetic and epigenetic mechanisms responsible for AF and their link with atrial fibrosis, then we will consider analogies with the pathophysiological mechanism in nongenetic AF, and discuss consequent therapeutic options.
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Affiliation(s)
- Gianmarco Arabia
- Cardiology Department, Spedali Civili Hospital, University of Brescia, Brescia, Italy
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | | | - Angelica Cersosimo
- Cardiology Department, Spedali Civili Hospital, University of Brescia, Brescia, Italy
| | - Maurizio Memo
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Francesco Mazzarotto
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
- National Heart and Lung Institute, Imperial College London (F.M., J. Ware), London, UK
| | | | - Manuel Cerini
- Cardiology Department, Spedali Civili Hospital, University of Brescia, Brescia, Italy
| | - Lin Yee Chen
- University of Minnesota (L.Y.C.), Minneapolis, USA
| | | | - Patrizia Benzoni
- Department of Biosciences, Università degli Studi di Milano, Milan, Italy
| | | | - Luca Bontempi
- Unit of Cardiology, Cardiac Electrophysiology and, Electrostimulation Laboratory, "Bolognini" Hospital of Seriate - ASST Bergamo Est, Bergamo, Italy
| | - Antonio Curnis
- Cardiology Department, Spedali Civili Hospital, University of Brescia, Brescia, Italy
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
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Horváth B, Kovács ZM, Dienes C, Óvári J, Szentandrássy N, Magyar J, Bányász T, Varró A, Nánási PP. Conductance Changes of Na + Channels during the Late Na + Current Flowing under Action Potential Voltage Clamp Conditions in Canine, Rabbit, and Guinea Pig Ventricular Myocytes. Pharmaceuticals (Basel) 2023; 16:ph16040560. [PMID: 37111317 PMCID: PMC10143054 DOI: 10.3390/ph16040560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/22/2023] [Accepted: 03/28/2023] [Indexed: 04/29/2023] Open
Abstract
Late sodium current (INa,late) is an important inward current contributing to the plateau phase of the action potential (AP) in the mammalian heart. Although INa,late is considered as a possible target for antiarrhythmic agents, several aspects of this current remained hidden. In this work, the profile of INa,late, together with the respective conductance changes (GNa,late), were studied and compared in rabbit, canine, and guinea pig ventricular myocytes using the action potential voltage clamp (APVC) technique. In canine and rabbit myocytes, the density of INa,late was relatively stable during the plateau and decreased only along terminal repolarization of the AP, while GNa,late decreased monotonically. In contrast, INa,late increased monotonically, while GNa,late remained largely unchanged during the AP in guinea pig. The estimated slow inactivation of Na+ channels was much slower in guinea pig than in canine or rabbit myocytes. The characteristics of canine INa,late and GNa,late were not altered by using command APs recorded from rabbit or guinea pig myocytes, indicating that the different shapes of the current profiles are related to genuine interspecies differences in the gating of INa,late. Both INa,late and GNa,late decreased in canine myocytes when the intracellular Ca2+ concentration was reduced either by the extracellular application of 1 µM nisoldipine or by the intracellular application of BAPTA. Finally, a comparison of the INa,late and GNa,late profiles induced by the toxin of Anemonia sulcata (ATX-II) in canine and guinea pig myocytes revealed profound differences between the two species: in dog, the ATX-II induced INa,late and GNa,late showed kinetics similar to those observed with the native current, while in guinea pig, the ATX-II induced GNa,late increased during the AP. Our results show that there are notable interspecies differences in the gating kinetics of INa,late that cannot be explained by differences in AP morphology. These differences must be considered when interpreting the INa,late results obtained in guinea pig.
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Affiliation(s)
- Balázs Horváth
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Zsigmond M Kovács
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Csaba Dienes
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - József Óvári
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Norbert Szentandrássy
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- Department of Basic Medical Sciences, Faculty of Dentistry, University of Debrecen, 4032 Debrecen, Hungary
| | - János Magyar
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- Division of Sport Physiology, Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Tamás Bányász
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - András Varró
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, 6720 Szeged, Hungary
| | - Péter P Nánási
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- Department of Dental Physiology and Pharmacology, Faculty of Dentistry, University of Debrecen, 4032 Debrecen, Hungary
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Effects of ranolazine on various outcomes in patients with stable angina: an updated meta-analysis. Hellenic J Cardiol 2022; 71:26-32. [PMID: 36481415 DOI: 10.1016/j.hjc.2022.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/24/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE We determined the effect of ranolazine vs. placebo in angina patients on 1) selective measures of the ischemic burden, 2) cardiovascular outcomes, including atrial fibrillation incidence, 3) the in-treatment glycohemoglobin levels and the permanent discontinuations because of side effects, and 4) the achieved between-arms blood pressure and heart rate difference. METHODS PubMed and Cochrane Collaboration Library databases were searched for eligible trials until end of September 2020. Trial quality was assessed by the Rob2 tool. Risk ratios or achieved mean differences during follow-up and 95% confidence interval (CI) of categorical or continuous outcomes, respectively, were calculated (random-effects model). The relationship between discontinuation rates and ranolazine's mean dose was investigated by meta-regression analysis. RESULTS We selected 18 trials (n = 12,995 patients in patients with macro or microvascular coronary heart disease. Achieved blood pressure and heart rate at rest were not different between randomized arms. Ranolazine administration compared to placebo was associated with an increase of 1) total exercise duration by 30 seconds (95% CI, 18-42), 2) time to 1 mm ST-segment depression by 44 seconds (95% CI, 30-54), and 3) time to angina onset by 40 seconds (95% CI, 30-54). On average, the incidence of atrial fibrillation was reduced by 25% following ranolazine treatment compared to placebo, while glycohemoglobin showed a mean decrease of 0.4% (95% CI, 0.3-0.5%). DISCUSSION Ranolazine remains an effective anti-ischemic drug, increases the angina-free exercise duration, delays the onset of ST-segment depression. The beneficial effects of ranolazine are extended to atrial fibrillation reduction rates and better glycemic control.
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Surma S, Romańczyk M, Filipiak KJ. Ranolazine - could an antianginal drug be used in stroke prevention? INTERNATIONAL JOURNAL OF CARDIOLOGY CARDIOVASCULAR RISK AND PREVENTION 2022; 14:200137. [PMID: 35677351 PMCID: PMC9168496 DOI: 10.1016/j.ijcrp.2022.200137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Stanisław Surma
- Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
- Club of Young Hypertensiologists, Polish Society of Hypertension, Gdańsk, Poland
| | - Monika Romańczyk
- Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Krzysztof J Filipiak
- Institute of Clinical Sciences, Maria Sklodowska-Curie Medical Academy, Warsaw, Poland
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Kaplan AD, Joca HC, Boyman L, Greiser M. Calcium Signaling Silencing in Atrial Fibrillation: Implications for Atrial Sodium Homeostasis. Int J Mol Sci 2021; 22:10513. [PMID: 34638854 PMCID: PMC8508839 DOI: 10.3390/ijms221910513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 09/14/2021] [Accepted: 09/14/2021] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most common type of cardiac arrhythmia, affecting more than 33 million people worldwide. Despite important advances in therapy, AF's incidence remains high, and treatment often results in recurrence of the arrhythmia. A better understanding of the cellular and molecular changes that (1) trigger AF and (2) occur after the onset of AF will help to identify novel therapeutic targets. Over the past 20 years, a large body of research has shown that intracellular Ca2+ handling is dramatically altered in AF. While some of these changes are arrhythmogenic, other changes counteract cellular arrhythmogenic mechanisms (Calcium Signaling Silencing). The intracellular Na+ concentration ([Na+])i is a key regulator of intracellular Ca2+ handling in cardiac myocytes. Despite its importance in the regulation of intracellular Ca2+ handling, little is known about [Na+]i, its regulation, and how it might be changed in AF. Previous work suggests that there might be increases in the late component of the atrial Na+ current (INa,L) in AF, suggesting that [Na+]i levels might be high in AF. Indeed, a pharmacological blockade of INa,L has been suggested as a treatment for AF. Here, we review calcium signaling silencing and changes in intracellular Na+ homeostasis during AF. We summarize the proposed arrhythmogenic mechanisms associated with increases in INa,L during AF and discuss the evidence from clinical trials that have tested the pharmacological INa,L blocker ranolazine in the treatment of AF.
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Affiliation(s)
- Aaron D. Kaplan
- Center for Biomedical Engineering and Technology, Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (A.D.K.); (H.C.J.); (L.B.)
- Division of Cardiovascular Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Humberto C. Joca
- Center for Biomedical Engineering and Technology, Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (A.D.K.); (H.C.J.); (L.B.)
| | - Liron Boyman
- Center for Biomedical Engineering and Technology, Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (A.D.K.); (H.C.J.); (L.B.)
| | - Maura Greiser
- Center for Biomedical Engineering and Technology, Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (A.D.K.); (H.C.J.); (L.B.)
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Ton AT, Nguyen W, Sweat K, Miron Y, Hernandez E, Wong T, Geft V, Macias A, Espinoza A, Truong K, Rasoul L, Stafford A, Cotta T, Mai C, Indersmitten T, Page G, Miller PE, Ghetti A, Abi-Gerges N. Arrhythmogenic and antiarrhythmic actions of late sustained sodium current in the adult human heart. Sci Rep 2021; 11:12014. [PMID: 34103608 PMCID: PMC8187365 DOI: 10.1038/s41598-021-91528-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/27/2021] [Indexed: 12/19/2022] Open
Abstract
Late sodium current (late INa) inhibition has been proposed to suppress the incidence of arrhythmias generated by pathological states or induced by drugs. However, the role of late INa in the human heart is still poorly understood. We therefore investigated the role of this conductance in arrhythmias using adult primary cardiomyocytes and tissues from donor hearts. Potentiation of late INa with ATX-II (anemonia sulcata toxin II) and E-4031 (selective blocker of the hERG channel) slowed the kinetics of action potential repolarization, impaired Ca2+ homeostasis, increased contractility, and increased the manifestation of arrhythmia markers. These effects could be reversed by late INa inhibitors, ranolazine and GS-967. We also report that atrial tissues from donor hearts affected by atrial fibrillation exhibit arrhythmia markers in the absence of drug treatment and inhibition of late INa with GS-967 leads to a significant reduction in arrhythmic behaviour. These findings reveal a critical role for the late INa in cardiac arrhythmias and suggest that inhibition of this conductance could provide an effective therapeutic strategy. Finally, this study highlights the utility of human ex-vivo heart models for advancing cardiac translational sciences.
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Affiliation(s)
- Anh Tuan Ton
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - William Nguyen
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Katrina Sweat
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Yannick Miron
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Eduardo Hernandez
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Tiara Wong
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Valentyna Geft
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Andrew Macias
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Ana Espinoza
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Ky Truong
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Lana Rasoul
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Alexa Stafford
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Tamara Cotta
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Christina Mai
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Tim Indersmitten
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Guy Page
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Paul E Miller
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Andre Ghetti
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Najah Abi-Gerges
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA.
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Mitochondrial Dysfunction in Atrial Fibrillation-Mechanisms and Pharmacological Interventions. J Clin Med 2021; 10:jcm10112385. [PMID: 34071563 PMCID: PMC8199309 DOI: 10.3390/jcm10112385] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 12/22/2022] Open
Abstract
Despite the enormous progress in the treatment of atrial fibrillation, mainly with the use of invasive techniques, many questions remain unanswered regarding the pathomechanism of the arrhythmia and its prevention methods. The development of atrial fibrillation requires functional changes in the myocardium that result from disturbed ionic fluxes and altered electrophysiology of the cardiomyocyte. Electrical instability and electrical remodeling underlying the arrhythmia may result from a cellular energy deficit and oxidative stress, which are caused by mitochondrial dysfunction. The significance of mitochondrial dysfunction in the pathogenesis of atrial fibrillation remains not fully elucidated; however, it is emphasized by the reduction of atrial fibrillation burden after therapeutic interventions improving the mitochondrial welfare. This review summarizes the mechanisms of mitochondrial dysfunction related to atrial fibrillation and current pharmacological treatment options targeting mitochondria to prevent or improve the outcome of atrial fibrillation.
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Yuan C, Luo W, Ren X, Ya M, Yan W, Hui Q. Ranolazine in the prevention and treatment of atrial fibrillation: A protocol for meta-analysis. Medicine (Baltimore) 2021; 100:e25437. [PMID: 33879675 PMCID: PMC8078434 DOI: 10.1097/md.0000000000025437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common clinical arrhythmia and a major cause of morbidity and mortality in clinical practice. This study aims to determine the ranolazine for prevention and treatment of atrial fibrillation. METHOD This study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-analysis for Protocols. Chinese electronic Database (CBM, Wanfang, and CNKI) and international electronic databases (PubMed, Embase, Cochrane Library, and Web of Science) will be searched for all relevant published articles. We will apply no language or the year of publication restrictions. Study selection, data collection, and assessment of study bias will be conducted independently by a pair of independent reviewers. The Cochrane risk of bias (ROB) tool will be used for the risk of bias assessment. The quality of evidence will be evaluated by Grading of Recommendations Assessment Development and Evaluation (GRADE) system. The statistical analysis of this meta-analysis will be calculated by Review manager version 5.3. RESULTS The results of this study will be published in a peer-reviewed journal. CONCLUSION This review will evaluate the value of ranolazine interventions for patients with AF, and provide meaningful conclusions or high-level evidence for clinical practice and further research. TRIAL REGISTRATION This study protocol was registered in open Science framework (OSF), (Registration DOI: 10.17605/OSF.IO/T6W9Q).
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Affiliation(s)
- Chengdai Yuan
- Department of Pharmacy, Baoji Traditional Chinese Medicine Hospital, Baoji, Shanxi
| | - Wei Luo
- The Second School of Clinical Medicine
| | | | - Maxiao Ya
- The Second School of Clinical Medicine
| | - Wenlong Yan
- The First School of Clinical Medicine, Lanzhou University
| | - Quanbin Hui
- Baoji People's Hospital, Baoji, Shanxi, China
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Role of Ranolazine in the Prevention and Treatment of Atrial Fibrillation in Patients with Left Ventricular Systolic Dysfunction: A Meta-Analysis of Randomized Clinical Trials. Diseases 2021; 9:diseases9020031. [PMID: 33923428 PMCID: PMC8167551 DOI: 10.3390/diseases9020031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Ranolazine has the potential to prevent atrial fibrillation (AF) and plays a role in rhythm control strategy for atrial fibrillation in various clinical settings. However, data on the use of ranolazine in patients with left ventricular (LV) systolic dysfunction are limited. The aims of this meta-analysis of randomized clinical trials are to investigate the efficacy and safety of ranolazine in AF patients with LV systolic dysfunction. PubMed and the Cochrane Database of Systematic Reviews were searched until July 2020. The efficacy outcomes included the incidence of new-onset AF, the rate of sinus rhythm restoration, and the time until sinus rhythm restoration. Safety endpoints were at death, and any adverse events were reported in the enrolled studies. We initially identified 204 studies and finally retrieved 5 RCTs. Three studies were analyzed in the meta-analysis. Among AF patients with LV systolic dysfunction, our meta-analysis showed that the combination of ranolazine to amiodarone significantly increased the sinus rhythm restoration rate compared to amiodarone alone (risk ratio (RR) 2.87, 95% confidence interval (CI) 2.48-3.32). Moreover, the time to sinus rhythm restoration was 2.46 h shorter in the ranolazine added to amiodarone group (95% CI: 2.27-2.64). No significant adverse events and proarrhythmias in the ranolazine group were identified. In conclusion, in AF patients with LV systolic dysfunction, ranolazine as an add-on therapy to amiodarone potentiates and accelerates the conversion of AF to sinus rhythm. Moreover, ranolazine shows good safety profiles. Further studies to investigate the effectiveness of ranolazine in the prevention of new-onset AF among patients with LV systolic dysfunction are needed.
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Affiliation(s)
- James A. Reiffel
- Electrophysiology Section, Division of Cardiology, Department of Medicine, Columbia University, New York, NY, USA
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Reiffel JA, Capucci A. "Pill in the Pocket" Antiarrhythmic Drugs for Orally Administered Pharmacologic Cardioversion of Atrial Fibrillation. Am J Cardiol 2021; 140:55-61. [PMID: 33144165 DOI: 10.1016/j.amjcard.2020.10.063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/16/2020] [Accepted: 10/21/2020] [Indexed: 12/19/2022]
Abstract
The therapy of atrial fibrillation often involves the use of a rhythm control strategy, in which 1 or more antiarrhythmic drugs (AAD), ablative procedures, and/or hybrid approaches involving both of these options are utilized in an attempt to restore and maintain sinus rhythm. For chronic therapy, an AAD is taken daily. However, for patients with symptomatic but infrequent, acute, but nondestabilizing episodes, the use of an AAD only at the time of an episode that can quickly restore sinus rhythm, generally as an out-patient, without the burden of a daily drug regimen, may be better. This is called "pill-in-the-pocket" therapy. This manuscript reviews the "pill-in-the-pocket" concept, traces its development from its origins using quinidine, to its expansion using class IC AADs, to the more recent investigation of ranolazine for this purpose. Who should get it, what it involves, its efficacy rates and concerns are all discussed.
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Eleutheroside B, a selective late sodium current inhibitor, suppresses atrial fibrillation induced by sea anemone toxin II in rabbit hearts. Acta Pharmacol Sin 2021; 42:209-217. [PMID: 32612277 DOI: 10.1038/s41401-020-0453-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 06/01/2020] [Indexed: 11/09/2022] Open
Abstract
Eleutheroside B (EB) is the main active constituent derived from the Chinese herb Acanthopanax senticosus (AS) that has been reported to possess cardioprotective effects. In this study we investigated the effects of EB on cardiac electrophysiology and its suppression on atrial fibrillation (AF). Whole-cell recording was conducted in isolated rabbit atrial myocytes. The intracellular calcium ([Ca2+]i) concentration was measured using calcium indicator Fura-2/AM fluorescence. Monophasic action potential (MAP) and electrocardiogram (ECG) synchronous recordings were conducted in Langendorff-perfused rabbit hearts using ECG signal sampling and analysis system. We showed that EB dose-dependently inhibited late sodium current (INaL), transient sodium current (INaT), and sea anemone toxin II (ATX II)-increased INaL with IC50 values of 167, 1582, and 181 μM, respectively. On the other hand, EB (800 μM) did not affect L-type calcium current (ICaL), inward rectifier potassium channel current (IK), and action potential duration (APD). Furthermore, EB (300 μM) markedly decreased ATX II-prolonged the APD at 90% repolarization (APD90) and eliminated ATX II-induced early afterdepolarizations (EADs), delayed afterdepolarizations (DADs), and triggered activities (TAs). Moreover, EB (200 μM) significantly suppressed ATX II-induced Na+-dependent [Ca2+]i overload in atrial myocytes. In the Langendorff-perfused rabbit hearts, application of EB (200 μM) or TTX (2 μM) substantially decreased ATX II-induced incidences of atrial fibrillation (AF), ventricular fibrillation (VF), and heart death. These results suggest that augmented INaL alone is sufficient to induce AF, and EB exerts anti-AF actions mainly via blocking INaL, which put forward the basis of pharmacology for new clinical application of EB.
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Antiarrhythmic Effect of Ranolazine in Combination with Selective NCX-Inhibition in an Experimental Model of Atrial Fibrillation. Pharmaceuticals (Basel) 2020; 13:ph13100321. [PMID: 33092020 PMCID: PMC7589655 DOI: 10.3390/ph13100321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/09/2020] [Accepted: 10/16/2020] [Indexed: 12/19/2022] Open
Abstract
The aim of this study was to investigate the effects of a combination of ranolazine with different selective inhibitors of the Na+/Ca2+-exchanger (NCX) in an established experimental model of atrial fibrillation (AF). Eighteen hearts of New Zealand white rabbits were retrogradely perfused. Atrial catheters were used to record monophasic action potentials (aPRR). Hearts were paced at three different cycle lengths. Thereby, atrial action potential durations (aAPD90), atrial effective refractory periods (aERP) and atrial post-repolarization refractoriness were obtained. Isoproterenol and acetylcholine were employed to increase the occurrence of AF. Thereafter, the hearts were assigned to two groups (n = 9 each group) and additionally perfused with a combination of 10 µM ranolazine and 1 µM of the selective NCX-inhibitor ORM-10103 (group A: Rano-ORM) or 10 µM ranolazine and 1 µM of another NCX-inhibitor, SEA0400 (group B: Rano-SEA). The infusion of Iso/ACh led to a shortening of aAPD90, aERP, aPRR and the occurrence of AF episodes was significantly increased. Additional perfusion with ranolazine and ORM-10103 (group A) significantly prolonged the refractory periods and aPRR and AF episodes were effectively reduced. In group B, Rano-SEA led to a slight decrease in aAPD90 while aERP and aPRR were prolonged. The occurrence of AF episodes was consecutively reduced. To our knowledge, this is the first study investigating the effect of ranolazine combined with different selective NCX-inhibitors in an isolated whole-heart model of AF. Both combinations prolonged aERP and aPRR and thereby suppressed the induction of AF.
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Del-Canto I, Gómez-Cid L, Hernández-Romero I, Guillem MS, Fernández-Santos ME, Atienza F, Such L, Fernández-Avilés F, Chorro FJ, Climent AM. Ranolazine-Mediated Attenuation of Mechanoelectric Feedback in Atrial Myocyte Monolayers. Front Physiol 2020; 11:922. [PMID: 32848863 PMCID: PMC7417656 DOI: 10.3389/fphys.2020.00922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/09/2020] [Indexed: 12/20/2022] Open
Abstract
Background Mechanical stretch increases Na+ inflow into myocytes, related to mechanisms including stretch-activated channels or Na+/H+ exchanger activation, involving Ca2+ increase that leads to changes in electrophysiological properties favoring arrhythmia induction. Ranolazine is an antianginal drug with confirmed beneficial effects against cardiac arrhythmias associated with the augmentation of INaL current and Ca2+ overload. Objective This study investigates the effects of mechanical stretch on activation patterns in atrial cell monolayers and its pharmacological response to ranolazine. Methods Confluent HL-1 cells were cultured in silicone membrane plates and were stretched to 110% of original length. The characteristics of in vitro fibrillation (dominant frequency, regularity index, density of phase singularities, rotor meandering, and rotor curvature) were analyzed using optical mapping in order to study the mechanoelectric response to stretch under control conditions and ranolazine action. Results HL-1 cell stretch increased fibrillatory dominant frequency (3.65 ± 0.69 vs. 4.35 ± 0.74 Hz, p < 0.01) and activation complexity (1.97 ± 0.45 vs. 2.66 ± 0.58 PS/cm2, p < 0.01) under control conditions. These effects were related to stretch-induced changes affecting the reentrant patterns, comprising a decrease in rotor meandering (0.72 ± 0.12 vs. 0.62 ± 0.12 cm/s, p < 0.001) and an increase in wavefront curvature (4.90 ± 0.42 vs. 5.68 ± 0.40 rad/cm, p < 0.001). Ranolazine reduced stretch-induced effects, attenuating the activation rate increment (12.8% vs. 19.7%, p < 0.01) and maintaining activation complexity—both parameters being lower during stretch than under control conditions. Moreover, under baseline conditions, ranolazine slowed and regularized the activation patterns (3.04 ± 0.61 vs. 3.65 ± 0.69 Hz, p < 0.01). Conclusion Ranolazine attenuates the modifications of activation patterns induced by mechanical stretch in atrial myocyte monolayers.
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Affiliation(s)
- Irene Del-Canto
- INCLIVA Health Research Institute, Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Valencia, Spain.,Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Lidia Gómez-Cid
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain
| | | | - María S Guillem
- ITACA Institute, Universitat Politècnica de València, Valencia, Spain
| | - María Eugenia Fernández-Santos
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain
| | - Felipe Atienza
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain
| | - Luis Such
- INCLIVA Health Research Institute, Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Valencia, Spain.,Department of Physiology, Universitat de València Estudi General, Valencia, Spain
| | - Francisco Fernández-Avilés
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain
| | - Francisco J Chorro
- INCLIVA Health Research Institute, Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Valencia, Spain.,Department of Cardiology, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain
| | - Andreu M Climent
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain.,ITACA Institute, Universitat Politècnica de València, Valencia, Spain
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15
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Horváth B, Hézső T, Kiss D, Kistamás K, Magyar J, Nánási PP, Bányász T. Late Sodium Current Inhibitors as Potential Antiarrhythmic Agents. Front Pharmacol 2020; 11:413. [PMID: 32372952 PMCID: PMC7184885 DOI: 10.3389/fphar.2020.00413] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 03/18/2020] [Indexed: 12/19/2022] Open
Abstract
Based on recent findings, an increased late sodium current (INa,late) plays an important pathophysiological role in cardiac diseases, including rhythm disorders. The article first describes what is INa,late and how it functions under physiological circumstances. Next, it shows the wide range of cellular mechanisms that can contribute to an increased INa,late in heart diseases, and also discusses how the upregulated INa,late can play a role in the generation of cardiac arrhythmias. The last part of the article is about INa,late inhibiting drugs as potential antiarrhythmic agents, based on experimental and preclinical data as well as in the light of clinical trials.
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Affiliation(s)
- Balázs Horváth
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Tamás Hézső
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Dénes Kiss
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Kornél Kistamás
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - János Magyar
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Division of Sport Physiology, University of Debrecen, Debrecen, Hungary
| | - Péter P. Nánási
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Department of Dental Physiology and Pharmacology, Faculty of Dentistry, University of Debrecen, Debrecen, Hungary
| | - Tamás Bányász
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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16
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Wenxin Keli Regulates Mitochondrial Oxidative Stress and Homeostasis and Improves Atrial Remodeling in Diabetic Rats. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2020; 2020:2468031. [PMID: 32104528 PMCID: PMC7040409 DOI: 10.1155/2020/2468031] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 01/07/2020] [Accepted: 01/25/2020] [Indexed: 12/13/2022]
Abstract
Mitochondrial dysfunction and oxidative stress play an important role in the pathogenesis of both atrial fibrillation (AF) and diabetes mellitus (DM). Wenxin Keli (WXKL), an antiarrhythmic traditional Chinese medicine, has been shown to prevent cardiac arrhythmias through modulation of cardiac ion channels. This study tested the hypothesis that WXKL can improve atrial remodeling in diabetic rats by restoring mitochondrial function. Primary atrial fibroblasts of neonatal SD rats were divided into four groups: control, hydrogen peroxide (H2O2), H2O2+WXKL 1 g/L, and H2O2+WXKL 3 g/L groups. Intracellular mitochondrial membrane potential (MMP), reactive oxygen species (ROS), and mitochondrial oxygen consumption were measured. SD male rats were randomly divided into three groups: control, DM, and DM+WXKL groups. Rats in the DM+WXKL group were treated with daily gavage of WXKL at 3 g/kg. After eight weeks, echocardiography, hemodynamic examination, histology, electrophysiology study, mitochondrial respiratory function, and western blots were assessed. H2O2 treatment led to increased ROS and decreased intracellular MMP and mitochondrial oxygen consumption in primary atrial fibroblasts. WXKL improved the above changes. DM rats showed increased atrial fibrosis, greater left atrial diameter, lower atrial conduction velocity, higher conduction heterogeneity, higher AF inducibility, and lower mitochondrial protein expression, and all these abnormal changes except for left atrial diameter were improved in the DM+WXKL group. WXKL improves atrial remodeling by regulating mitochondrial function and homeostasis and reducing mitochondrial ROS in diabetic rats.
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17
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Huang CLH, Wu L, Jeevaratnam K, Lei M. Update on antiarrhythmic drug pharmacology. J Cardiovasc Electrophysiol 2020; 31:579-592. [PMID: 31930579 DOI: 10.1111/jce.14347] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/22/2019] [Accepted: 01/03/2020] [Indexed: 12/28/2022]
Abstract
Cardiac arrhythmias constitute a major public health problem. Pharmacological intervention remains mainstay to their clinical management. This, in turn, depends upon systematic drug classification schemes relating their molecular, cellular, and systems effects to clinical indications and therapeutic actions. This approach was first pioneered in the 1960s Vaughan-Williams classification. Subsequent progress in cardiac electrophysiological understanding led to a lag between the fundamental science and its clinical translation, partly addressed by The working group of the European Society of Cardiology (1991), which, however, did not emerge with formal classifications. We here utilize the recent Revised Oxford Classification Scheme to review antiarrhythmic drug pharmacology. We survey drugs and therapeutic targets offered by the more recently characterized ion channels, transporters, receptors, intracellular Ca2+ handling, and cell signaling molecules. These are organized into their strategic roles in cardiac electrophysiological function. Following analysis of the arrhythmic process itself, we consider (a) pharmacological agents directly targeting membrane function, particularly the Na+ and K+ ion channels underlying depolarizing and repolarizing events in the cardiac action potential. (b) We also consider agents that modify autonomic activity that, in turn, affects both the membrane and (c) the Ca2+ homeostatic and excitation-contraction coupling processes linking membrane excitation to contractile activation. Finally, we consider (d) drugs acting on more upstream energetic and structural remodeling processes currently the subject of clinical trials. Such systematic correlations of drug actions and arrhythmic mechanisms at different molecular to systems levels of cardiac function will facilitate current and future antiarrhythmic therapy.
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Affiliation(s)
- Christopher L-H Huang
- Department of Biochemistry and Physiological Laboratory, University of Cambridge, Cambridge, UK.,Key Laboratory of Medical Electrophysiology of Ministry of Education, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China.,Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Lin Wu
- Key Laboratory of Medical Electrophysiology of Ministry of Education, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China.,Department of Cardiology, Peking University First Hospital, Beijing, China
| | | | - Ming Lei
- Key Laboratory of Medical Electrophysiology of Ministry of Education, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China.,Department of Pharmacology, University of Oxford, Oxford, UK
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18
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Del Canto I, Santamaría L, Genovés P, Such-Miquel L, Arias-Mutis O, Zarzoso M, Soler C, Parra G, Tormos Á, Alberola A, Such L, Chorro FJ. Effects of the Inhibition of Late Sodium Current by GS967 on Stretch-Induced Changes in Cardiac Electrophysiology. Cardiovasc Drugs Ther 2019; 32:413-425. [PMID: 30173392 DOI: 10.1007/s10557-018-6822-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Mechanical stretch increases sodium and calcium entry into myocytes and activates the late sodium current. GS967, a triazolopyridine derivative, is a sodium channel blocker with preferential effects on the late sodium current. The present study evaluates whether GS967 inhibits or modulates the arrhythmogenic electrophysiological effects of myocardial stretch. METHODS Atrial and ventricular refractoriness and ventricular fibrillation modifications induced by acute stretch were studied in Langendorff-perfused rabbit hearts (n = 28) using epicardial multiple electrodes and high-resolution mapping techniques under control conditions and during the perfusion of GS967 at different concentrations (0.03, 0.1, and 0.3 μM). RESULTS On comparing ventricular refractoriness, conduction velocity and wavelength obtained before stretch had no significant changes under each GS967 concentration while atrial refractoriness increased under GS967 0.3 μM. Under GS967, the stretch-induced changes were attenuated, and no significant differences were observed between before and during stretch. GS967 0.3 μM diminished the normal stretch-induced changes resulting in longer (less shortened) atrial refractoriness (138 ± 26 ms vs 95 ± 9 ms; p < 0.01), ventricular refractoriness (155 ± 18 ms vs 124 ± 16 ms; p < 0.01) and increments in spectral concentration (23 ± 5% vs 17 ± 2%; p < 0.01), the fifth percentile of ventricular activation intervals (46 ± 8 ms vs 31 ± 3 ms; p < 0.05), and wavelength of ventricular fibrillation (2.5 ±0.5 cm vs 1.7 ± 0.3 cm; p < 0.05) during stretch. The stretch-induced increments in dominant frequency during ventricular fibrillation (control = 38%, 0.03 μM = 33%, 0.1 μM = 33%, 0.3 μM = 14%; p < 0.01) and the stretch-induced increments in arrhythmia complexity index (control = 62%, 0.03μM = 41%, 0.1 μM = 32%, 0.3 μM = 16%; p < 0.05) progressively decreased on increasing the GS967 concentration. CONCLUSIONS GS967 attenuates stretch-induced changes in cardiac electrophysiology.
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Affiliation(s)
- Irene Del Canto
- CIBER CV. Carlos III Health Institute, Madrid, Spain.,Department of Electronics, Universitat Politècnica de València, Valencia, Spain
| | - Laura Santamaría
- Department of Physiology, Valencia University - Estudi General, Valencia, Spain
| | | | - Luis Such-Miquel
- CIBER CV. Carlos III Health Institute, Madrid, Spain.,Department of Physiotherapy, Valencia University - Estudi General, Valencia, Spain
| | | | - Manuel Zarzoso
- Department of Physiotherapy, Valencia University - Estudi General, Valencia, Spain
| | - Carlos Soler
- Department of Physiology, Valencia University - Estudi General, Valencia, Spain
| | - Germán Parra
- Department of Physiology, Valencia University - Estudi General, Valencia, Spain
| | - Álvaro Tormos
- CIBER CV. Carlos III Health Institute, Madrid, Spain.,Department of Electronics, Universitat Politècnica de València, Valencia, Spain
| | - Antonio Alberola
- CIBER CV. Carlos III Health Institute, Madrid, Spain.,Department of Physiology, Valencia University - Estudi General, Valencia, Spain
| | - Luis Such
- CIBER CV. Carlos III Health Institute, Madrid, Spain.,Department of Physiology, Valencia University - Estudi General, Valencia, Spain
| | - Francisco J Chorro
- CIBER CV. Carlos III Health Institute, Madrid, Spain. .,Service of Cardiology, Valencia University Clinic Hospital, INCLIVA, Valencia, Spain. .,Department of Medicine, Valencia University - Estudi General, Valencia, Spain. .,Servicio de Cardiología, Hospital Clínico Universitario, Avda. Blasco Ibañez 17, 46010, Valencia, Spain.
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19
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Efficacy of Wenxin Keli Plus Amiodarone versus Amiodarone Monotherapy in Treating Recent-Onset Atrial Fibrillation. Cardiol Res Pract 2018; 2018:6047271. [PMID: 30622821 PMCID: PMC6304890 DOI: 10.1155/2018/6047271] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/21/2018] [Accepted: 11/06/2018] [Indexed: 11/17/2022] Open
Abstract
Background Use of amiodarone (AMIO) in atrial fibrillation (AF) has significant side effects over prolonged periods. Wenxin Keli (WXKL), a Chinese herb extract, has been shown to be effective in atrial-selective inhibiting peak I Na and hence beneficial in treating atrial arrhythmias, including atrial fibrillation. The aim of this randomized controlled trial was to evaluate potential effects of AMIO plus WXKL on conversion rate and time in patients with recent-onset AF. Methods A total of 41 patients (71 ± 12 years, 44% male) with recent-onset (<48 h) AF eligible for conversion were randomized to receive either intravenous amiodarone (loading dose 5 mg/kg in 1 hour followed by 50 mg/h; n=21) or amiodarone with same dosage plus oral WXKL 18 g thrice daily (n=20) for 24 hours. Results Conversion rate at 24 hours was of no difference between the two groups (75.0% vs. 81.0%, P=0.72); however, conversion time was markedly shorter in the AMIO + WXKL group compared to the AMIO group (291 ± 235 minutes vs. 725 ± 475 minutes, P=0.003). There were no serious adverse events during the study. Conclusion Administration of amiodarone plus WXKL for recent-onset AF conversion was safe and effective, with faster sinus rhythm restoration compared with amiodarone alone.
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20
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Dan GA, Dobrev D. Antiarrhythmic drugs for atrial fibrillation: Imminent impulses are emerging. IJC HEART & VASCULATURE 2018; 21:11-15. [PMID: 30225340 PMCID: PMC6138883 DOI: 10.1016/j.ijcha.2018.08.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/15/2018] [Accepted: 08/30/2018] [Indexed: 12/19/2022]
Abstract
Rhythm and rate strategies are considered equivalent for the management of atrial fibrillation (AF). Moreover, both strategies are intended for improving symptoms and quality of life. Despite the clinical availability of several antiarrhythmic drugs (AAD) the alternatives for the patient with comorbidities are significantly fewer because of the concern regarding many adverse effects, including proarrhythmias. The impetuous development of AF ablation gave rise to a false impression that AAD are a second line therapy. All these statements reflect, in fact, the weakness of the classical paradigm and classification regarding AAD and the gap between the current knowledge of AF mechanism and determinants and the "classical" AAD non-discriminatory action. A new paradigm in development of effective and safe AAD is based on modern knowledge of vulnerable parameters involved in the genesis and perpetuation of AF. New AAD will target specific triggers of AF and ion currents which are expressed preferentially in fibrillatory atrium. Such targets will include repolarizing currents and channels, as ultrarapid potassium current, two pore potassium current, the acetylcholine-gated potassium current, small-conductance calcium-dependent potassium channels, but, also, molecular targets involved in intracellular calcium kinetics, as Ca2+-calmodulin-dependent protein kinase, ryanodine receptors and non-coding miRNA. New mechanistic discoveries link AF to inflammation and modern anti-cytokine drugs. There is still a long way to win between basic research and clinical practice, but, without any doubt, antiarrhythmic drug therapy will remain and develop as a cornerstone therapy for AF not in conflict, but complementary and alternative to interventional therapy.
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Affiliation(s)
- Gheorghe-Andrei Dan
- Carol Davila Medicine University, Bucharest, Romania
- Colentina University Hospital, Bucharest, Romania
| | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
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21
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Bazoukis G, Tse G, Letsas KP, Thomopoulos C, Naka KK, Korantzopoulos P, Bazoukis X, Michelongona P, Papadatos SS, Vlachos K, Liu T, Efremidis M, Baranchuk A, Stavrakis S, Tsioufis C. Impact of ranolazine on ventricular arrhythmias - A systematic review. J Arrhythm 2018; 34:124-128. [PMID: 29657587 PMCID: PMC5891418 DOI: 10.1002/joa3.12031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 11/29/2017] [Indexed: 12/15/2022] Open
Abstract
Ranolazine is a new medication for the treatment of refractory angina. However, except its anti-anginal properties, it has been found to act as an anti-arrhythmic. The aim of our systematic review is to present the existing data about the impact of ranolazine in ventricular arrhythmias. We searched MEDLINE and Cochrane databases as well clinicaltrials.gov until September 1, 2017 to find all studies (clinical trials, observational studies, case reports/series) reported data about the impact of ranolazine in ventricular arrhythmias. Our search revealed 14 studies (3 clinical trials, 2 observational studies, 8 case reports, 1 case series). These data reported a beneficial impact of ranolazine in ventricular tachycardia/fibrillation, premature ventricular beats, and ICD interventions in different clinical settings. The existing data highlight the anti-arrhythmic properties of ranolazine in ventricular arrhythmias.
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Affiliation(s)
- George Bazoukis
- Department of Cardiology Catheterization Laboratory Evangelismos General Hospital of Athens Athens Greece
| | - Gary Tse
- Department of Medicine and Therapeutics Faculty of Medicine Chinese University of Hong Kong Hong Kong China.,Li Ka Shing Institute of Health Sciences Faculty of Medicine Chinese University of Hong Kong Hong Kong China
| | - Konstantinos P Letsas
- Department of Cardiology Catheterization Laboratory Evangelismos General Hospital of Athens Athens Greece
| | | | - Katerina K Naka
- Second Department of Cardiology School of Medicine University of Ioannina Ioannina Greece
| | | | - Xenophon Bazoukis
- Department of Cardiology General Hospital of Ioannina, "G Hatzikosta" Ioannina Greece
| | - Paschalia Michelongona
- Department of Cardiology Catheterization Laboratory Evangelismos General Hospital of Athens Athens Greece
| | - Stamatis S Papadatos
- Faculty Department of Internal Medicine Athens School of Medicine Sotiria General Hospital National and Kapodistrian University of Athens Athens Greece
| | - Konstantinos Vlachos
- Department of Cardiology Catheterization Laboratory Evangelismos General Hospital of Athens Athens Greece
| | - Tong Liu
- Department of Cardiology Tianjin Institute of Cardiology Second Hospital of Tianjin Medical University Tianjin China
| | - Michael Efremidis
- Department of Cardiology Catheterization Laboratory Evangelismos General Hospital of Athens Athens Greece
| | - Adrian Baranchuk
- Division of Cardiology, Electrophysiology and Pacing Kingston General Hospital Queen's University Kingston ON Canada
| | - Stavros Stavrakis
- University of Oklahoma Health Sciences Center Oklahoma City Oklahoma
| | - Costas Tsioufis
- First Cardiology Clinic Hippokration Hospital University of Athens Athens Greece
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22
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Abstract
For arrhythmia triggers that are secondary to dysfunctional intracellular Ca2+ cycling, there are few, if any, agents that specifically target the Ca2+ handling machinery. However, several candidates have been proposed in the literature. Here we review the idea that these agents or their derivatives will prove invaluable in clinical applications in the future.
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Affiliation(s)
- Penelope A Boyden
- Department of Pharmacology, Center for Molecular Therapeutics, Columbia University, New York, New York.
| | - Godfrey L Smith
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
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23
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Batul SA, Gopinathannair R. Atrial Fibrillation in Heart Failure: a Therapeutic Challenge of Our Times. Korean Circ J 2017; 47:644-662. [PMID: 28955382 PMCID: PMC5614940 DOI: 10.4070/kcj.2017.0040] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/27/2017] [Indexed: 11/11/2022] Open
Abstract
Atrial fibrillation (AF) and heart failure (HF) are growing cardiovascular disease epidemics worldwide. There has been an exponential increase in the prevalence of AF and HF correlating with an increased burden of cardiac risk factors and improved survival rates in patients with structural heart disease. AF is associated with adverse prognostic outcomes in HF and is most evident in mild-to-moderate left ventricular (LV) dysfunction where the loss of "atrial kick" translates into poorer quality of life and increased mortality. In the absence of underlying structural heart disease, arrhythmia can independently contribute to the development of cardiomyopathy. Together, these 2 conditions carry a high risk of thromboembolism due to stasis, inflammation and cellular dysfunction. Stroke prevention with oral anticoagulation (OAC) remains a mainstay of treatment. Pharmacologic rate and rhythm control remain limited by variable efficacy, intolerance and adverse reactions. Catheter ablation for AF has resulted in a paradigm shift with evidence indicating superiority over medical therapy. While its therapeutic success is high for paroxysmal AF, it remains suboptimal in persistent AF. A better mechanistic understanding of AF as well as innovations in ablation technology may improve patient outcomes in the future. Refractory cases may benefit from atrioventricular junction ablation and biventricular pacing. The value of risk factor modification, especially with regard to obesity, sleep apnea, hypertension and diabetes, cannot be emphasized enough. Close interdisciplinary collaboration between HF specialists and electrophysiologists is an essential component of good long-term outcomes in this challenging population.
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Affiliation(s)
- Syeda Atiqa Batul
- Division of Cardiology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY USA
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24
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Onal B, Gratz D, Hund TJ. Ca 2+/calmodulin-dependent kinase II-dependent regulation of atrial myocyte late Na + current, Ca 2+ cycling, and excitability: a mathematical modeling study. Am J Physiol Heart Circ Physiol 2017; 313:H1227-H1239. [PMID: 28842436 DOI: 10.1152/ajpheart.00185.2017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) affects more than three million people per year in the United States and is associated with high morbidity and mortality. Both electrical and structural remodeling contribute to AF, but the molecular pathways underlying AF pathogenesis are not well understood. Recently, a role for Ca2+/calmodulin-dependent protein kinase II (CaMKII) in the regulation of persistent "late" Na+ current ( INa,L) has been identified. Although INa,L inhibition is emerging as a potential antiarrhythmic strategy in patients with AF, little is known about the mechanism linking INa,L to atrial arrhythmogenesis. A computational approach was used to test the hypothesis that increased CaMKII-activated INa,L in atrial myocytes disrupts Ca2+ homeostasis, promoting arrhythmogenic afterdepolarizations. Dynamic CaMKII activity and regulation of multiple downstream targets [ INa,L, L-type Ca2+ current, phospholamban, and the ryanodine receptor sarcoplasmic reticulum Ca2+-release channel (RyR2)] were incorporated into an existing well-validated computational model of the human atrial action potential. Model simulations showed that constitutive CaMKII-dependent phosphorylation of Nav1.5 and the subsequent increase in INa,L effectively disrupt intracellular atrial myocyte ion homeostasis and CaMKII signaling. Specifically, increased INa,L promotes intracellular Ca2+ overload via forward-mode Na+/Ca2+ exchange activity, which greatly increases RyR2 open probability beyond that observed for CaMKII-dependent phosphorylation of RyR2 alone. Increased INa,L promotes atrial myocyte repolarization defects (afterdepolarizations and alternans) in the setting of acute β-adrenergic stimulation. We anticipate that our modeling efforts will help identify new mechanisms for atrial NaV1.5 regulation with direct relevance for human AF. NEW & NOTEWORTHY Here, we present a novel computational model to study the effects of late Na+ current ( INa,L) in human atrial myocytes. Simulations predict that INa,L promotes intracellular accumulation of Ca2+, with subsequent dysregulation of Ca2+/calmodulin-dependent protein kinase II (CaMKII) signaling and ryanodine receptor 2-mediated Ca2+ release. Although INa,L plays a small role in regulating atrial myocyte excitability at baseline, CaMKII-dependent enhancement of the current promoted arrhythmogenic dynamics. Listen to this article's corresponding podcast at http://ajpheart.podbean.com/e/camkii-dependent-regulation-of-atrial-late-sodium-current-and-excitability/ .
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Affiliation(s)
- Birce Onal
- The Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center , Columbus, Ohio.,Department of Biomedical Engineering, College of Engineering, The Ohio State University , Columbus, Ohio
| | - Daniel Gratz
- The Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center , Columbus, Ohio.,Department of Biomedical Engineering, College of Engineering, The Ohio State University , Columbus, Ohio
| | - Thomas J Hund
- The Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center , Columbus, Ohio.,Department of Biomedical Engineering, College of Engineering, The Ohio State University , Columbus, Ohio.,Department of Internal Medicine, The Ohio State University Wexner Medical Center , Columbus, Ohio
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25
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Heijman J, Ghezelbash S, Dobrev D. Investigational antiarrhythmic agents: promising drugs in early clinical development. Expert Opin Investig Drugs 2017; 26:897-907. [PMID: 28691539 PMCID: PMC6324729 DOI: 10.1080/13543784.2017.1353601] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Although there have been important technological advances for the treatment of cardiac arrhythmias (e.g., catheter ablation technology), antiarrhythmic drugs (AADs) remain the cornerstone therapy for the majority of patients with arrhythmias. Most of the currently available AADs were coincidental findings and did not result from a systematic development process based on known arrhythmogenic mechanisms and specific targets. During the last 20 years, our understanding of cardiac electrophysiology and fundamental arrhythmia mechanisms has increased significantly, resulting in the identification of new potential targets for mechanism-based antiarrhythmic therapy. Areas covered: Here, we review the state-of-the-art in arrhythmogenic mechanisms and AAD therapy. Thereafter, we focus on a number of antiarrhythmic targets that have received significant attention recently: atrial-specific K+-channels, the late Na+-current, the cardiac ryanodine-receptor channel type-2, and the small-conductance Ca2+-activated K+-channel. We highlight for each of these targets available antiarrhythmic agents and the evidence for their antiarrhythmic effect in animal models and early clinical development. Expert opinion: Targeting AADs to specific subgroups of well-phenotyped patients is likely necessary to detect improved outcomes that may be obscured in the population at large. In addition, specific combinations of selective AADs may have synergistic effects and may enable a mechanism-based tailored antiarrhythmic therapy.
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Affiliation(s)
- Jordi Heijman
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Shokoufeh Ghezelbash
- Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Essen, Germany
| | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Essen, Germany
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26
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Chadda KR, Jeevaratnam K, Lei M, Huang CLH. Sodium channel biophysics, late sodium current and genetic arrhythmic syndromes. Pflugers Arch 2017; 469:629-641. [PMID: 28265756 PMCID: PMC5438422 DOI: 10.1007/s00424-017-1959-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 02/14/2017] [Indexed: 12/11/2022]
Abstract
Arrhythmias arise from breakdown of orderly action potential (AP) activation, propagation and recovery driven by interactive opening and closing of successive voltage-gated ion channels, in which one or more Na+ current components play critical parts. Early peak, Na+ currents (INa) reflecting channel activation drive the AP upstroke central to cellular activation and its propagation. Sustained late Na+ currents (INa-L) include contributions from a component with a delayed inactivation timecourse influencing AP duration (APD) and refractoriness, potentially causing pro-arrhythmic phenotypes. The magnitude of INa-L can be analysed through overlaps or otherwise in the overall voltage dependences of the steady-state properties and kinetics of activation and inactivation of the Na+ conductance. This was useful in analysing repetitive firing associated with paramyotonia congenita in skeletal muscle. Similarly, genetic cardiac Na+ channel abnormalities increasing INa-L are implicated in triggering phenomena of automaticity, early and delayed afterdepolarisations and arrhythmic substrate. This review illustrates a wide range of situations that may accentuate INa-L. These include (1) overlaps between steady-state activation and inactivation increasing window current, (2) kinetic deficiencies in Na+ channel inactivation leading to bursting phenomena associated with repetitive channel openings and (3) non-equilibrium gating processes causing channel re-opening due to more rapid recoveries from inactivation. All these biophysical possibilities were identified in a selection of abnormal human SCN5A genotypes. The latter presented as a broad range of clinical arrhythmic phenotypes, for which effective therapeutic intervention would require specific identification and targeting of the diverse electrophysiological abnormalities underlying their increased INa-L.
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Affiliation(s)
- Karan R Chadda
- Faculty of Health and Medical Sciences, University of Surrey, VSM Building, Guildford, GU2 7AL, UK
- Physiological Laboratory, University of Cambridge, Downing Street, Cambridge, CB2 3EG, UK
| | - Kamalan Jeevaratnam
- Faculty of Health and Medical Sciences, University of Surrey, VSM Building, Guildford, GU2 7AL, UK
- School of Medicine, Perdana University-Royal College of Surgeons Ireland, 43400, Serdang, Selangor Darul Ehsan, Malaysia
| | - Ming Lei
- Department of Pharmacology, University of Oxford, Oxford, OX1 3QT, UK
| | - Christopher L-H Huang
- Physiological Laboratory, University of Cambridge, Downing Street, Cambridge, CB2 3EG, UK.
- Department of Biochemistry, University of Cambridge, Hopkins Building, Cambridge, CB2 1QW, UK.
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