Pacemaker selectivity: influence on rabbit atria of ionic environment and of alinidine, a possible anion antagonist

HCN channels and heart rate

Hyperpolarization and Cyclic Nucleotide (HCN) -gated channels represent the molecular correlates of the "funny" pacemaker current (I(f)), a current activated by hyperpolarization and considered able to influence the sinus node function in generating cardiac impulses. HCN channels are a family of six transmembrane domain, single pore-loop, hyperpolarization activated, non-selective cation channels. This channel family comprises four members: HCN1-4, but there is a general agreement to consider HCN4 as the main isoform able to control heart rate. This review aims to summarize advanced insights into the structure, function and cellular regulation of HCN channels in order to better understand the role of such channels in regulating heart rate and heart function in normal and pathological conditions. Therefore, we evaluated the possible therapeutic application of the selective HCN channels blockers in heart rate control.

The funny current: cellular basis for the control of heart rate

The 'funny' (pacemaker, I(f)) current, first described almost 30 years ago in sinoatrial node (SAN) myocytes, is a mixed sodium/potassium inward current, activated on hyperpolarisation in the diastolic range of voltages. 'Funny' (f) channels are activated by intracellular cyclic adenosine monophosphate (cAMP) concentrations according to a mechanism mediating regulation of heart rate by the autonomic nervous system, as well as by voltage hyperpolarisation. Structural subunits of native f-channels are the hyperpolarisation-activated cyclic nucleotide-gated (HCN) channels; of the four HCN isoforms known, HCN4 is the most highly expressed in SAN tissue. The I(f) current is a natural target in the search for drugs aimed specifically at affecting heart rate, given its function in pacemaking. Increased heart rate has a negative influence on clinical outcome in patients with cardiovascular disease, and indeed is also an established risk factor for cardiovascular and all-cause mortality in the general population. Clearly, therefore, independent reduction of heart rate, through inhibition of the I(f) current, appears to be a suitable therapeutic option for patients with ischaemic heart disease.beta-Adrenoceptor antagonists (beta-blockers) reduce intracellular cAMP levels, and a substantial part of their negative chronotropic effect is therefore attributable to a reduction of the I(f) current. However, neither beta-blockers nor Ca(2+) channel antagonists, both of which have traditionally been used to reduce myocardial ischaemia, are 'pure' heart rate-lowering drugs. These agents may, in fact, have adverse cardiovascular and noncardiovascular effects.Conversely, the novel heart rate-reducing agent ivabradine is a specific blocker of f-channels, hence a selective inhibitor of the pacemaker I(f) current in the SAN. Ivabradine slows heart rate by reducing the I(f) current-regulated steepness of the diastolic depolarisation in SAN myocytes, thereby increasing diastolic duration, without altering action potential duration or causing negative inotropy. As such, ivabradine is particularly useful in patients with chronic stable angina pectoris. Further clinical studies are ongoing to evaluate the efficacy of ivabradine in patients with coronary heart disease, left ventricular dysfunction and heart failure. This short article reviews the current state of knowledge of the properties of the 'funny' current in relation to exploitation of the I(f) function in pacemaking generation and modulation for the pharmacological control of heart rate.

Physiology and pharmacology of the cardiac pacemaker (“funny”) current

First described over a quarter of a century ago, the cardiac pacemaker "funny" (I(f)) current has been extensively characterized since, and its role in cardiac pacemaking has been thoroughly demonstrated. A similar current, termed I(h), was later described in different types of neurons, where it has a variety of functions and contributes to the control of cell excitability and plasticity. I(f) is an inward current activated by both voltage hyperpolarization and intracellular cAMP. In the heart, as well as generating spontaneous activity, f-channels mediate autonomic-dependent modulation of heart rate: beta-adrenergic stimulation accelerates, and vagal stimulation slows, cardiac rate by increasing and decreasing, respectively, the intracellular cAMP concentration and, consequently, the f-channel degree of activation. Four isoforms of hyperpolarization-activated, cyclic nucleotide-gated (HCN) channels have been cloned more recently and shown to be the molecular correlates of native f-channels in the heart and h-channels in the brain. Individual HCN isoforms have kinetic and modulatory properties which differ quantitatively. A comparison of their biophysical properties with those of native pacemaker channels provides insight into the molecular basis of the pacemaker current properties and, together with immunolabelling and other detection techniques, gives information on the pattern of HCN isoform distribution in different tissues. Because of their relevance to cardiac pacemaker activity, f-channels are a natural target of drugs aimed at the pharmacological control of heart rate. Several agents developed for their ability to selectively reduce heart rate act by a specific inhibition of f-channel function; these substances have a potential for the treatment of diseases such as angina and heart failure. In the near future, devices based on the delivery of f-channels in situ, or of a cellular source of f-channels (biological pacemakers), will likely be developed for use in therapies for diseases of heart rhythm with the aim of replacing electronic pacemakers.

Pharmacological tests of the mechanism of the periodic rhythm caused by veratramine in the sinoatrial node of the guinea pig

1. We investigated the effects of several drugs and extracellular ions on the periodic sinoatrial node rhythm caused by high concentrations of veratramine (>2 microM) in isolated guinea pig sinus atria. 2. During the active phase of this rhythm, pacemaker activity appeared to be due to transient afterdepolarizations resembling the delayed afterdepolarizations attributed to Ca++-induced Ca++ release in cardiac tissue. 3. Ryanodine (200-2200 nM) did not decrease the transient afterdepolarizations, and instead increased the heart rate during the active phase, prolonged the active phase, and sometimes caused conversion to regular rhythm. 4. Dichlorobenzamyl (10-110 microM), a blocker of electrogenic Na+-Ca++ exchange, did not slow or stop beating during periodic rhythm, but rather increased average heart rate and, at a higher concentration, caused conversion to regular rhythm. 5. Ouabain (0.1 microM), an inhibitor of the sodium pump and electrogenic Na+-K+ exchange, had little effect on veratramine periodic rhythm, but at higher concentrations it caused increased average heart rate and conversion to regular rhythm. 6. The chronotropic effect of Ca++ was normally weakly positive; however, in the presence of veratramine, and before the appearance of periodic rhythm, the chronotropic effect of Ca++ was weakly negative, and was associated with destabilization of the heart rate, leading to frequency oscillations or periodic rhythm. 7. Veratramine changed the chronotropic effect of K+ from weakly negative to moderately positive. 8. When half the Na+ or Cl- in the bathing medium was replaced by an impermeant ion, in the absence of veratramine the average heart rate was slightly decreased, whereas, in the presence of veratramine and periodic rhythm the average rate was increased, although the increase was not statistically significant in the case of low Na+. 9. These observations indicate that Ca++-induced Ca++ release, Na+-Ca++ exchange, and probably electrogenic Na+-K+ exchange play no important role in generation of periodic rhythm. The increased K+ dependence suggests an altered pacemaker mechanism.

Antiischemic and antiarrhythmic activities of some novel alinidine analogs in the rat heart

The antiischemic and antiarrhythmic effects of alinidine and a number of novel alinidine analogs were examined by using perfused rat-heart models. In the isolated working rat heart, the alinidine analog TH91:21 (10 microM; a butyl derivative) significantly increased the postischemic recovery of the heart in terms of both power and efficiency when compared with the control group. In the in situ perfused heart model, this same compound, along with TH91:22 (10 microM; a pentyl derivative) also significantly reduced the severity of both ischemia- and reperfusion-induced arrhythmias in both paced and unpaced hearts. Thus this study is the first to demonstrate the potent antiarrhythmic efficacy of two novel alinidine analogs TH91:21 and TH91:22, with TH91:21 also demonstrated to be a potent antiischemic agent in the isolated working rat heart. Although the mode of action of these compounds remains unclear, results from this study suggest that it is not simply a result of bradycardia or blockade of KATP channels, two actions these compounds possess. These compounds thus possess a novel and beneficial pharmacologic profile worthy of further study.

Zatebradine attenuates cyclic AMP-related positive chronotropic but not inotropic responses in isolated, perfused right atria of the dog

1. Inhibition of I(f) or ICa by zatebradine has been reported in mammalian SA nodal cells. We thus investigated whether zatebradine differentially attenuates the positive chronotropic and inotropic responses to norepinephrine, isoproterenol, NKH 477 (an adenylyl cyclase activator), 3-isobutyl-1-methylxanthine (IBMX) and Bay k 8644 (a calcium channel agonist) in the isolated, blood-perfused dog atrium. 2. When zatebradine (0.03-1 mumol) decreased sinus rate from 104 +/- 4.5 to 73 +/- 4.9 beats/min dose-dependently, it selectively attenuated the positive chronotropic but not inotropic responses to norepinephrine in a dose-related manner. Zatebradine decreased the norepinephrine-induced tachycardia (by approximately 80% from the control) more effectively than the spontaneous sinus rate (by approximately 30% from the control). 3. Zatebradine similarly attenuated the positive chronotropic but not inotropic responses to isoproterenol, NKH 477 and IBMX. Fifty per cent inhibition doses of zatebradine (0.10-0.18 mumol) for the chronotropic responses to each substance were not significantly different. 4. On the other hand, zatebradine attenuated neither positive chronotropic nor inotropic responses to Bay k 8644. 5. We therefore suggest that zatebradine selectively attenuates the positive chronotropic but not inotropic responses to cyclic AMP-related substances due to inhibition of I(f) but not ICa in the dog heart.

Alinidine prevents hypoperfusion-induced transmural flow redistribution in isolated paced rat hearts

1. The effect of alinidine on transmural flow redistribution during hypoperfusion was studied in the isolated rat heart. 2. Low flow perfusion of paced (5 Hz) rat Langendorff preparations with Tyrode's solution for 60 min resulted in loss of left ventricular pressure amplitude and contracture. 3. In the presence of 45.6 mumol/L alinidine in the hypoperfusion medium contractility was maintained and contracture was missing. 4. Myocardial sphere densities were assessed by infusion of fluorescent microspheres after 60 min of hypoperfusion. Histomorphometric evaluation of the left ventricular wall indicated marked redistribution of myocardial flow to the epicardium. Endo/epicardial quotients of sphere densities were significantly greater in alinidine-treated hearts. 5. Perfusion of hearts with 45.6 mumol/L alinidine for 30 min at a pressure of 80 cmH2O decreased coronary flow and contractility, but did not change the transmural quotient of sphere densities. 6. These results show that in isolated rat hearts with a ventricular wall of only 3-4 mm thickness severe hypoperfusion induces a shift in transmural flow distribution which is prevented by alinidine.

Selective inhibition by E4080, a novel bradycardic agent, of positive chronotropic responses to norepinephrine in isolated dog hearts

E4080, a novel bradycardic agent acts on various ionic currents including the hyperpolarization-activated inward current (I(f)), L-type Ca2+ current (ICa) and ATP-sensitive K+ (K+ATP) current in mammalian heart and vascular tissues. We thus investigated the chronotropic and inotropic effects of E4080 and its interaction with the positive cardiac responses to norepinephrine, 3-isobutyl-1-methyl-xanthine (IBMX) and Bay k 8644 in the isolated, blood-perfused dog right atria and left ventricles. E4080 (0.01-1 mumol) decreased the sinus rate and atrial and ventricular contractile forces in a dose-related manner. Glibenclamide (3 mumol) partly blocked the decrease in atrial force but not the decreases in sinus rate and ventricular force induced by E4080. Atropine (10 nmol) did not affect the negative cardiac responses to E4080. E4080 (0.01-1 mumol) inhibited the positive chronotropic responses to norepinephrine and IBMX dose dependently, but did not inhibit the positive inotropic ones in isolated atria. E4080 affected neither positive chronotropic nor inotropic responses to Bay k 8644. These results suggest that (1) the activation of K+ATP channels by E4080 is partly related to the decrease in atrial force but not the decreases in sinus rate and ventricular force, and (2) the selective inhibition of E4080 of the cyclic AMP-dependent positive chronotropic responses but not inotropic ones is probably due to the inhibition of I(f) rather than other properties, e.g., activation of K+ATP channels and inhibition of ICa in the dog heart.

Antiarrhythmic versus antifibrillatory actions: inference from experimental studies

Pathophysiology of the coronary circulation is a major contributor to altering the myocardial substrate, rendering the heart susceptible to the onset of arrhythmias associated with sudden cardiac death. Antiarrhythmic drug therapy for the prevention of sudden cardiac death has been provided primarily on the basis of trial and error and in some instances based on ill-suited preclinical evaluations. The findings of the Cardiac Arrhythmia Suppression Trial (CAST) requires a reexamination of the manner in which antiarrhythmic drugs are developed before entering into clinical testing. The major deficiency in this area of experimental investigation has been the lack of animal models that would permit preclinical studies to identify potentially useful or deleterious therapeutic agents. Further, CAST has emphasized the need to distinguish between pharmacologic interventions that suppresses nonlethal disturbances of cardiac rhythm as opposed to those agents capable of preventing lethal ventricular tachycardia or ventricular fibrillation. Preclinical models for the testing of antifibrillatory agents must consider the fact that the superimposition of transient ischemic events on an underlying pathophysiologic substrate makes the heart susceptible to lethal arrhythmias. Proarrhythmic events, not observed in the normal heart, may become manifest only when the myocardial substrate has been altered. We describe a model of sudden cardiac death that may more closely simulate the clinical state in humans who are at risk. The experimental results show a good correlation with clinical data regarding agents known to reduce the incidence of lethal arrhythmias as well as those showing proarrhythmic actions.

Classifying antiarrhythmic actions: by facts or speculation

Classification of antiarrhythmic actions is reviewed in the context of the results of the Cardiac Arrhythmia Suppression Trials, CAST 1 and 2. Six criticisms of the classification recently published (The Sicilian Gambit) are discussed in detail. The alternative classification, when stripped of speculative elements, is shown to be similar to the original classification. Claims that the classification failed to predict the efficacy of antiarrhythmic drugs for the selection of appropriate therapy have been tested by an example. The antiarrhythmic actions of cibenzoline were classified in 1980. A detailed review of confirmatory experiments and clinical trials during the past decade shows that predictions made at the time agree with subsequent results. Classification of the effects drugs actually have on functioning cardiac tissues provides a rational basis for finding the preferred treatment for a particular arrhythmia in accordance with the diagnosis.

The selective bradycardic effects of zatebradine (UL-FS 49) do not adversely affect left ventricular function in conscious pigs with chronic coronary artery occlusion

This study was designed to test whether the selective bradycardic effects of zatebradine (UL-FS 49) were altered in the setting of chronic mild left ventricular dysfunction secondary to a myocardial infarction. We therefore administered four doses of UL-FS 49 at 15-min intervals (cumulative doses of 10, 30, 100, and 300 micrograms/kg) to eight normal conscious pigs and to seven pigs in which the left circumflex coronary artery was occluded 3 weeks previously. Left ventricular dysfunction in this second group of animals was manifested by an increase in left ventricular end-diastolic pressure (LVEDP, 11 +/- 2 mmHg vs. 7 +/- 1 mmHg, respectively; p less than 0.05) and a decrease in LVdP/dtmax (3020 +/- 210 mmHg vs. 3720 +/- 210 mmHg, respectively; p less than 0.05). The results showed that UL-FS 49 was equally effective in reducing heart rate in both groups of animals [from 126 +/- 4 to 95 +/- 2 beats/min and from 140 +/- 5 to 98 +/- 6 beats/min for the normal animals and for the animals with a chronic myocardial infarction (MI), respectively]. The duration of left ventricular systole was not affected, but the duration of diastole was prolonged from 290 +/- 10 msec to 420 +/- 20 msec in the normal animals and from 250 +/- 10 msec to 430 +/- 30 msec in the animals with MI (both p less than 0.05). Up to 100 micrograms/kg UL-FS 49 did not affect arterial blood pressure, whereas LVdP/dtmax and cardiac output decreased by less than 10% in either group.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodynamic effects of alinidine (ST 567) at rest and during exercise in patients with chronic congestive heart failure

Selective inhibition of sinus node function offers the possibility to decrease heart rate and reduce myocardial oxygen consumption in patients with impaired cardiac function, if myocardial contractility is not further attenuated. To study the influence of a specific sinus node inhibitor on myocardial function, alinidine was given to 10 patients with chronic congestive heart failure and stable sinus rhythm. Radionuclide ventriculography was used to monitor left ventricular function at rest and during a standardized exercise protocol. After a bolus injection of 45 mg of alinidine followed by infusion of 10 mg/hr, radionuclide studies were repeated 1.5 and 3 hours later. The results show that left ventricular ejection fraction, stroke volume, and end-diastolic volume index were essentially unchanged, whereas cardiac index decreased by 10% at rest and during exercise. Heart rate decreased markedly by 14% at rest and by 13% during exercise. Systolic blood pressure was reduced by 6% at rest and by 14% during exercise. As a result of the marked decrease of these two parameters, a pronounced effect was seen on rate-pressure product with a 19% decrease at rest and a 24% decrease during exercise. No significant side effects were observed. Alinidine might be given to patients with chronic congestive heart failure and sinus rhythm in doses up to 45 mg without exerting a clinically relevant negative inotropic effect. Therefore it may represent an alternative to other drugs when a decrease in heart rate is desired to reduce myocardial oxygen consumption.

Alinidine antagonizes the myocardial effects of adenosine

The bradycardiac drug alinidine (2.8-182.3 microM) antagonized the negative inotropic effect of adenosine in isolated left rat atria in a non-competitive fashion. A 50% reduction of the maximal adenosine effect was achieved with 64.6 microM alinidine. The shortening of the action potential duration and the suppression of slow action potentials in guinea pig atria by 1-10 microM adenosine could be abolished by 5.7 microM alinidine. Adenosine (1 mM) exerted a negative inotropic effect on isolated strips from the right ventricle of rat heart exposed to 0.36 microM isoproterenol, an effect which was fully antagonized by 91.1 microM alinidine. Addition of 1 mM adenosine to spontaneously beating isolated rat atria induced pronounced bradycardia. Under these conditions, the bradycardiac agent alinidine increased the contractile rate concentration dependently (11.4-182.3 microM), while the chemically unrelated bradycardiac compound UL-FS 49 did not accelerate the beat frequency. As alinidine antagonized all the cardiac actions of adenosine that we tested, it may be concluded that the drug interferes with A1-receptor-mediated effects.

Alinidine reverses the descending staircase of isolated rat atria by an antimuscarinic action

Contractile force of isolated atria from most mammalian species increases with the rate of electrical stimulation, resulting in an ascending staircase. In contrast, in the rat, contractile force decreases with increasing rate of stimulation (descending staircase). The bradycardic and antianginal drug alinidine (5.7-91.2 mumol/l) reversed the descending staircase to ascending by a positive inotropic effect at higher stimulation rates. Maximal positive inotropy was obtained with 45.6 mumol/l, a concentration which also caused maximal bradycardia in spontaneously beating atria. Concentrations of 1 mumol/l of the antimuscarinic compounds atropine as well as the quaternary salt ipratropium bromide also reversed the descending staircase of rat atria. Addition of alinidine did not cause any further increase in force of contraction under these conditions. Addition of 1 mumol/l physostigmine to isolated left atria from guinea pigs for blockade of acetylcholinesterase decreased contractility at all stimulation rates, but did not change the ascending character of the staircase. Alinidine antagonized the negative inotropic effect of physostigmine. The known antimuscarinic action of alinidine was quantified in electrically driven (0.25 Hz) left rat atria by antagonism of the negative inotropic effect of oxotremorine (0.01-10 mumol/l). Alinidine acted as a strictly competitive antagonist with a pA2 of 5.82. In isolated papillary muscle from guinea pigs, pretreated with reserpine for depletion of catecholamines, carbachol (0.1-3000 mumol/l) exerted positive inotropic effects. Alinidine antagonized also this effect in a competitive fashion with a pA2 value of 5.58.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative heart rate reduction--alinidine versus metoprolol

In a double-blind randomized protocol the effectiveness of the specific bradycardic agent alinidine (0.6 mg.kg-1 i.v.) was compared to that of the betablocker metoprolol (0.035 mg.kg-1 i.v.). Twenty-four coronary artery disease patients undergoing a bypass procedure with an intraoperative heart rate increase of more than 20% were included. Patients with a concomitant intraoperative mean arterial pressure increase of more than 30% or with an intraoperative wedge pressure higher than 15 mmHg (2.0 kPa) were excluded. After application of alinidine and metoprolol, heart rate decreased significantly (P less than 0.01) in the alinidine group from 88 +/- 19 beats per min to 72 +/- 13 and in the metoprolol group from 82 +/- 16 to 72 +/- 12. Baseline values were not obtained. Compared to the hemodynamic changes in the metoprolol group, the alterations of pulmonary capillary wedge pressure (PCWP) (P less than 0.05), stroke volume index (SVI) (P less than 0.05), left ventricular stroke work index (LVSWI) (P less than 0.01) and right ventricular stroke work index (RVSWI) (P less than 0.05) in the alinidine group were statistically significantly different. PCWP remained unchanged after alinidine and increased in the metoprolol group (1.4 +/- 0.4 to 1.6 +/- 0.4 kPa). In the alinidine group LVSWI (43.1 +/- 15 to 49.2 +/- 18 g-m.m-2), RVSWI (5.1 +/- 4 to 6.6 +/- 3 g-m.m-2) and SVI (37.2 +/- 12.2 to 42.5 +/- 12.8 ml.m-2) increased.(ABSTRACT TRUNCATED AT 250 WORDS)

Drug effects on the sinus node. A clinical perspective

The direct and indirect effects of drugs on the sinoatrial (SA) node are described in relation to basic cellular mechanisms and clinical applications. The effects of the different classes of antiarrhythmic agents are considered in terms of their direct depressant and excitatory actions. Indirect actions, particularly autonomic effects, are also discussed. Clinical aspects of the pharmacologic management of disorders of sinus node function such as the bradycardia-tachycardia syndrome, inappropriate sinus tachycardia, sinus bradycardia, and the identification of sinus node dysfunction by drug effects are considered in detail.

Comparison of the haemodynamic effects of the selective bradycardic agent UL-FS 49, with those of propranolol during treadmill exercise in dogs

1. To clarify whether the bradycardic agent UL-FS 49 exhibits a positive inotropic effect even in the absence of improvement in regional myocardial function of an underperfused myocardial area, this study was undertaken in dogs with unimpaired coronary flow. 2. We also investigated the haemodynamic and functional effects of the negative chronotropic and inotropic beta-adrenoceptor blocker propranolol. 3. UL-FS 49 did not depress total or regional myocardial performance. Moreover, an increase in positive left ventricular dp/dt max at rest suggests a positive inotropic effect of UL-FS 49. 4. Propranolol, in contrast to UL-FS 49, led to a marked reduction in positive dp/dt max, stroke volume and systolic wall thickening at rest and during exercise. Additionally, propranolol decreased the exercise values of cardiac output, left ventricular work and left ventricular power to a far greater extent than UL-FS 49. 5. In contrast to propranolol, the selective bradycardic agent UL-FS 49 did not decrease total or regional ventricular performance and caused less reduction in cardiodynamic parameters during exercise. 6. These results suggest that patients with moderate coronary insufficiency or patients with coronary vessel disease and mild left ventricular failure may attain a higher exercise limit under selective bradycardia with UL-FS 49 in comparison to that possible with a beta-adrenoceptor antagonist, such as propranolol.

Alinidine modifies the pacemaker current in sheep Purkinje fibers

(1) The "specific bradycardic agent" alinidine reduces the slope of the diastolic depolarization in sinoatrial tissue and Purkinje fibers. In short Purkinje fibers of sheep, alinidine (28 microM) decreased the pacemaker current by a dual action. The voltage dependence of if activation was shifted in the hyperpolarizing direction by 7.8 +/- 0.6 mV (n = 18, p less than 0.001) and the conductance of the fully activated if current was reduced to 73 +/- 2% (n = 18, p less than 0.001) of its control value. These effects were reversible and dose-dependent. (2) Ionophoretic injections of alinidine caused reversible reductions of the diastolic depolarization rate and simultaneous transient hyperpolarizing shifts of the if activation range. (3) Some prolongation of the action potential duration was observed at 28 microM and more pronounced at higher concentration. This was presumably the consequence of a reduction by alinidine of outward repolarizing current carried by the background inward rectifier and plateau current ix. (4) The action of alinidine on if resulted in a slower activation of a reduced fraction of the pacemaker current at the maximal diastolic potential level. This explains the decrease of the diastolic depolarization rate observed in Purkinje fibers.

Control of catecholamine-induced tachycardia with alinidine in the anesthetized dog

Sinus tachycardia is a common complication of beta-adrenergic agonist therapy. A new selective bradycardic agent, N-allyl-clonidine, or alinidine, has been found effective against sinus tachycardia caused by a variety of stimuli. To determine whether it would also control catecholamine-induced sinus tachycardia, the effects of alinidine in two groups of anesthetized dogs treated with either dobutamine, 10 microg/ kg/min, or isoproterenol, 0.1 microg/kg/min, were studied. In both groups, alinidine significantly reduced the heart rate (P < .0001 in the dobutamine group, and P < .005 in the isoproterenol-infused dogs). The other hemodynamic effects of dobutamine were not adversely affected by alinidine, while the isoproterenol-infused dogs had a further afterload reduction when treated with alinidine. It is concluded that alinidine is effective against catecholamine-induced sinus tachycardia, possibly through mechanisms not related to beta-adrenergic receptors.

Effects of alinidine on exercise-induced regional contractile dysfunction in dogs

The effects of the bradycardiac agent alinidine on hemodynamic parameters and regional contractile function were investigated in 6 chronically instrumented dogs trained to submit to 5 consecutive treadmill exercise runs. The experiments were performed during stenosis of the circumflex branch of the left coronary artery (LCX). After 2 control runs which had induced regional contractile dysfunction of comparable intensity, alinidine was infused intravenously at a dosage of 1 mg/kg per 5 min. The drug significantly reduced the resting function of both the LCX area (-16%) and the area perfused by the unstenosed anterior descending branch of the left coronary artery (LAD, -3%). However, the exercise-induced dysfunction of the LCX area was markedly improved in the 1st post-drug run and completely abolished during the 2nd and 3rd post-drug runs. As indicated by the reduction of heart rate (-18%) and positive dp/dtmax (-24%) during peak exercise, this improvement may be attributed to a bradycardiac and a negative inotropic effect of this drug. Further benefit may be ascribed to a decreased in arterial blood pressure after alinidine.

Electrophysiological study of alinidine in voltage clamped rabbit sino-atrial node cells

Electrophysiological effects of alinidine on rabbit sino-atrial node cells were examined. Alinidine was applied in concentrations between 0.3 and 100 micrograms/ml and decreased the spontaneous frequency in a dose-dependent manner. The maximum rate of rise and the amplitude of action potentials of the spontaneously beating rabbit sino-atrial node were decreased in the presence of alinidine concentrations higher than 10 and 100 micrograms/ml, respectively. The maximum diastolic potential was depolarized by alinidine at 100 micrograms/ml. The main effect of alinidine was a dose-dependent decrease in slope of diastolic depolarization (a prolongation of the cycle length) and a delayed repolarization of the action potential. In voltage clamp experiments, alinidine suppressed the slow inward current (Is) and the outward current (Ik) dose dependently, without altering steady-state inactivation of Is (f infinity) and the activation of Ik (p infinity). The hyperpolarization-activated inward current (Ih) was also reduced. These results suggested that alinidine decreased Is, Ik and Ih due to reduction in the conductance of these current systems. The changes in the ionic currents in the presence of alinidine can explain the changes in configuration of the action potential and must contribute to the negative chronotropic action of alinidine.

Safety and efficacy of alinidine in symptom-free asthmatics

Alinidine is a new bradycardic agent which has been shown to be beneficial in the treatment of coronary heart disease. Patients with both coronary heart disease and obstructive lung disease are difficult to treat, because the use of beta-blockers in them is greatly limited by their potential to provoke bronchospasm. Alinidine has no beta-blocking, muscarinic or quinidine-like properties. In a randomized double-blind cross-over study the heart rate reducing effect and safety of alinidine 40 mg p.o. has been examined in 12 symptom-free asthmatics. Alinidine significantly reduced mean heart rate from 81 +/- 10.5 beats/min to 65 +/- 9.7 beats/min two hours after administration. Forced expiratory volume in one second (FEV1), vital capacity (CV), airway resistance (Raw), functional residual capacity (FRC), and specific airway conductance (SGaw) were not affected. It is concluded that alinidine did not influence respiratory function in patients with bronchial hypersensitivity.

Anion-channel blockade with alinidine: a specific bradycardic drug for coronary heart disease without negative inotropic activity?

In 14 patients undergoing cardiac catheterization for suspected coronary artery disease, alinidine, 0.6 mg/kg, was administered intravenously to determine its effects on left ventricular (LV) function, coronary blood flow and myocardial oxygen consumption. To assess effects independent of changes in heart rate (HR), measurements were made at spontaneous and matched pacing HRs. At spontaneous HR, alinidine decreased HR from 70 +/- 2 to 61 +/- 3 beats/min (p less than 10(-6]. Peak rate of LV pressure decreased from 1,652 +/- 92 to 1,371 +/- 80 mm Hg/s (p less than 10(-5] and Vmax decreased from 47 +/- 3 to 41 +/- 2 s-1 (p less than 10(-4]. Coronary sinus blood flow decreased from 109 +/- 9 to 89 +/- 7 ml/min (p less than 0.01) and myocardial oxygen consumption from 10.9 +/- 1.0 to 9.0 +/- 0.8 ml O2/min (p less than 0.05). At a matched pacing HR of 98 +/- 3 beats/min before and after alinidine administration, peak rate of LV pressure decreased from 1,984 +/- 124 to 1,793 +/- 106 mm Hg/s (p less than 10(-4] and Vmax from 60 +/- 5 to 56 +/- 4 s-1 (p less than 0.02). Coronary sinus blood flow and myocardial oxygen consumption were not significantly changed at matched pacing HRs. The time constant of the first 40 ms of LV isovolumic relaxation was prolonged by alinidine only during spontaneous HR. Thus, alinidine results in a bradycardia-dependent decrease in myocardial oxygen consumption. It has negative inotropic properties independent of changes in HR and so is not a pure bradycardia-specific agent.

Effects of atriopeptins I, II and III on atrial contractility, sinus nodal rate (guinea pig) and agonist-induced tension in rabbit aortic strips

The cardiovascular effects of atriopeptins (AP) I, II and III were compared in spontaneously beating or electrically stimulated guinea pig atria and in rabbit aortic strips precontracted by various agonists. Atriopeptins did not significantly affect sinus nodal rate or atrial contractility. AP II and III, although more potent than nitroprusside, exhibited similar vasorelaxant profiles against vascular strips maximally stimulated by norepinephrine, high [K+]0 or Ca2+ ionophore A23187. The ability of atriopeptins and nitroprusside to relax ionophore-induced vascular tension implies an intracellular mechanism of action.

Cardiovascular effects of bevantolol, a selective beta 1-adrenoceptor antagonist with a novel pharmacological profile

Bevantolol was more potent in blocking the chronotropic than the hypotensive effects of isoprenaline in pithed rats. Bevantolol itself induced bradycardia, so that it was not possible to estimate the pA2 from nonparallel dose-response curves relating isoprenaline concentration to tachycardia. Bevantolol caused hypertension in pithed rats, an effect attenuated by phentolamine, implying that bevantolol may be an alpha-adrenoceptor agonist. Bevantolol potentiated the pressor effects of noradrenaline, the maximum potentiation equalling that produced by prior chemical sympathectomy with guanethidine, implying that bevantolol may block noradrenaline uptake. In isolated atria bevantolol-induced bradycardia was associated with a positive shift in take-off potential, a reduction in the maximum rate of depolarization (Vmax), and a lengthening of action potential duration (APD). No change in the slope of the slow diastolic depolarization occurred except at the highest concentration (18 mumol l(-1). In atrial and ventricular muscle bevantolol reduced Vmax and overshoot potential, implying reduction of fast inward sodium current (Class I antiarrhythmic action). In pithed rats bevantolol lengthened the P-R interval in the ECG, and produced atrioventricular (A-V) block, and bundle-branch block. In isolated A-V nodal preparations, intranodal conduction time was greatly increased, implying restriction of inward current through calcium channels responsible for nodal depolarization. Bevantolol had no negative inotropic effect in pithed rats, or in isolated atria, and did not alter the positive inotropic effect of raised extracellular calcium concentration, implying absence of restriction of current through calcium channels controlling contraction of the myocardium.

Decrease in bradycardic effect of AQ-A 39 and alinidine in guinea-pig sinoatrial node depolarized by high external K+-concentration

The effects of the two "specific bradycardic agents" AQ-A 39 and alinidine on the spontaneous electrical discharge rate of intact guinea-pig sinus node preparations were investigated. At high external K+-concentrations (10.8 and 16.2 mmol/l) the bradycardic effect of the two drugs was diminished or abolished. In contrast, the negative chronotropic effect of the reference compound verapamil ("Ca2+-antagonist") was enhanced. These results show that the bradycardic effects of AQ-A 39 and alinidine are diminished in depolarized preparations, which makes it unlikely that in intact sinus node preparations the mechanism of action is the same as that of "Ca2+-antagonists".

A classification of antiarrhythmic actions reassessed after a decade of new drugs

The past decade has seen the introduction of many new class 1 drugs, restricting fast inward current. Confirmative evidence has been obtained that the antiarrthymic action of lidocaine and diphenylhydantoin is indeed due to their effect as class 1 agents depressing conduction. The original class 3 drug, amiodarone, is increasingly in use as an antiarrhythmic of first choice for WPW and for arrhythmias associated with hypertrophic myopathy, and as a reserve drug in resistant arrhythmias of other types. Other compounds delaying repolarization have proved to be clinically effective as antiarrhythmics. In addition to their class 2 antiarrhythymic action exhibited acutely, on long-term treatment beta blockers have a class 3 action, which might be, at least in part, responsible for the protection of postinfarction patients against sudden death. Recent research suggests that inhibition of slow inward current may lead, as a secondary consequence of lowered [Ca]i, to improved cell-to-cell conduction. Finally, all but one of the new antiarrhythmic drugs, none of which existed in 1972, have turned out to possess one or more of the four classes of action originally described. This can hardly be a coincidence. The single exception, alinidine, a selective bradycardic agent, may restrict anionic currents, which would constitute a fifth class of action, but this is far from proved.

Interactions between alinidine and responses to acetylcholine, dopamine and 5-hydroxytryptamine of specific Helix central neurones

Intracellular recordings were made from identified neurones in the brain of the snail, Helix aspersa. The effect of alinidine on the excitatory and inhibitory responses to acetylcholine and dopamine and on the excitatory response to 5-hydroxytryptamine (5-HT) was investigated. Alinidine was found to reduce the responses to acetylcholine and 5-HT and the excitatory response to dopamine but had no effect on the dopamine inhibitory response. pA2 values were determined for alinidine antagonism to indicate relative potency. The pA2 values against the excitatory responses of acetylcholine, dopamine and 5-HT were 5.8, 5.6 and 5.5 respectively. The pA2 value against acetylcholine inhibition was 3.5. From these studies it is suggested that alinidine interacts preferentially with the sodium inonophore, to a lesser degree with the chloride ionophore and not at all with the potassium ionophore on Helix central neurones.

Pharmacological mapping of regional effects in the rabbit heart of some new antiarrhythmic drugs

In vitro preparations of rabbit heart were made from which measurements of effective refractory period (ERP), atrio-Hisian (A-H) and His-Purkinje (H-P) conduction times could be obtained, analogous to electrophysiological measurements customarily carried out in vivo. Intracellular potentials also were recorded from the sino-atrial (SA) node, atrium, bundle of His, preterminal Purkinje fibres and papillary muscles. The effects of a range of concentrations of three new antiarrhythmic drugs, melperone, cibenzoline and alinidine were compared, the lower concentrations studied corresponding to clinical levels. At low concentrations the effects of melperone, inducing bradycardia and lengthening ERP, could be attributed to prolongation of action potential duration (APD) in the sinus node and atrial and ventricular tissues. The slope of slow diastolic depolarization was not altered, nor was there any change in A-H or H-P conduction time, or in maximum rate of depolarization (MRD). At higher concentrations melperone had a substantial class 1 action, but there was no negative inotropic effect, or other evidence of restriction of slow inward current. Cibenzoline was primarily a class 1 agent but also lengthened APD to some extent in the SA node and in atrial and ventricular muscle, but not in Purkinje fibres. APD thus became more uniform along the ventricular conducting pathway. Cibenzoline also depressed contractions and increased A-H conduction time, implying restriction of slow inward current. The bradycardia could thus be attributed to a slowing of both depolarization and repolarization in the SA node, without any change in slope of the slow diastolic depolarization. Conduction time was increased in all tissues. 8 Alinidine greatly reduced the slope of the slow diastolic depolarization and slightly lengthened APD in the SA node. MRD was also reduced in the SA node, and A-H conduction time was increased, implying some restriction of slow inward current. However, there was no negative inotropic effect. 9 Alinidine had no significant effect on MRD in atrium, ventricle or Purkinje cells, nor was H-P conduction time altered, implying absence of effect on fast inward current. APD was moderately lengthened in atrium and ventricle but not in Purkinje cells. 10 It was concluded that the effects of the drugs in the sinus node and on ERP and on A-H and H-P conduction times could be accounted for by their selective cellular actions in different regions of the heart.

Comparison of the bradycardic effects of alinidine (St 567), AQ-A 39 and verapamil on guinea-pig sinoatrial node superfused with different Ca2+ and NaCl solutions

Two new substances, alinidine (St 567) and AQ-A 39, previously described as 'specific bradycardic agents' were investigated with respect to their effects on the rate of electrical discharges from sinus nodes of isolated right guinea-pig atria. Both substances decreased the discharge rate concentration dependently within a wide range (3-100 micrograms/ml). Low external Ca2+ (0.18 mM) increased and low external NaCl (62 mM) decreased the rate lowering effect of alinidine as well as of AQ-A 39. In contrast, the reference compound verapamil (an inhibitor of slow inward current) was less effective in low Ca2+ and more effective in low NaCl. The similar reactions of alinidine and AQ-A 39 are discussed with respect to their different chemical structure and different electrophysiological action patterns as described so far.

Comparative effects of alinidine and propranolol in ischaemic heart disease

The effects of single oral doses of alinidine 40 mg, propranolol 40 mg or placebo during a maximal exercise test on a bicycle ergometer in patients with angina pectoris were studied in a randomised, double blind study. 2 and 5 h after drug intake a small fall in resting heart rate and systolic blood pressure was observed both after alinidine and propranolol. At a fixed work load both drugs decreased heart rate, systolic blood pressure, double product and the extent of ST segment depression. Total work performed and time to appearance of angina pectoris were increased 2 h alinidine and propranolol. The same effects were still apparent 5 h after propranolol but not after alinidine. At peak exercise neither drug had any effect on the extent of ischaemic ST segment depression.

Effects on rabbit nodal, atrial, ventricular and Purkinje cell potentials of a new antiarrhythmic drug, cibenzoline, which protects against action potential shortening in hypoxia

1 The effects of cibenzoline (UP 339-01), a new anti-arrhythmic drug, have been investigated in various cardiac tissues. 2 UP 339-01 produced a bradycardia, due partly to prolongation of the intracellularly recorded sinus node action potential duration (APD) and partly to depression of the maximum rate of depolarization (MRD). The slope of the slow diastolic depolarization was not significantly reduced. 3 UP 339-01 was not a beta-adrenoceptor antagonist. 4 UP 339-01 was negatively inotropic, and shifted the relation between [Ca2+]o and force of contractions to the right, and increased A-H conduction time. It was concluded that UP 339-01 restricted slow inward current. 5 In all cardiac tissues depolarized by fast inward current, UP 339-01 caused a reduction in MRD and conduction velocity. The reduction was similar in atrial muscle, His and terminal Purkinje fibres, but in papillary muscle the effect was about half as great. On desheathed frog nerve UP 339-01 had a local anaesthetic potency slightly greater than that of procaine. 6 APD was significantly prolonged in a dose-related manner in ventricular muscle but to a lesser extent in the bundle of His and atrial tissue. In terminal Purkinje fibres APD50 and APD90 were unaltered, but the transient outward current ("notch') was abolished, resulting in a lengthening of APD20. 7 The effective and functional refractory periods of the A-V node and right bundle branch were both lengthened by UP 339-01 in a dose-related manner, and the difference between them was greatly increased. 8 UP 339-01 (2.63 microM) completely prevented the shortening of APD90 induced by hypoxia, and the shortening of APD50 and APD20 was much attenuated. There was no protection against hypoxic depression of contractions. 9 It was concluded that UP 339-01 is a highly active class 1 anti-arrhythmic agent with additional class 3 and 4 properties.

Differential actions on rabbit nodal, atrial, Purkinje cell and ventricular potentials of melperone, a bradycardic agent delaying repolarization: effects of hypoxia

1 Melperone, a butyrophenone tranquillizer, caused bradycardia in vivo and in vitro. 2 Although Melperone had alpha-adrenoceptor antagonist activity in the pithed rat, it was not a beta-adrenoceptor antagonist, nor was it a cholinoceptor agonist. 3 The bradycardic action could be attributed almost entirely to a prolongation by Melperone of action potential duration (APD) in sinus node cells, with little effect on the slow diastolic depolarization. 4 APD was prolonged by Melperone in atrial and ventricular muscle, and most of all in the bundle of His, but only moderately in the terminal Purkinje cells. 5 In all cardiac tissues depolarized by fast inward current. Melperone caused a dose-related reduction in the maximum rate of depolarization and conduction velocity. On desheathed frog nerve Melperone had a local anaesthetic potency equal to that of procaine. 6 There was no negative inotropic effect in cardiac muscle, nor interference with A-V nodal conduction, from which it was inferred that Melperone did not restrict slow inward current. 7 Melperone did not reduce hypoxic shortening of APD relative to the initial value at the start of hypoxia, but because APD was already lengthened by Melperone in normoxic conditions, APD90 during hypoxia remained close to normal values. There was no protection against hypoxic depression of contractions. 8 It was concluded that Melperone had class 1 and class 3 antiarrythmic actions and merited trial as an antiarrhythmic drug.